Bone suture

ABSTRACT

An anchor connected with a suture is moved through a passage between opposite sides of a bone. The anchor is then pivoted to change its orientation. A second anchor is connected with the suture. While tension is maintained in the suture, the suture is secured against movement relative to the anchors. This may be done by tying the suture or by using a suture retainer to hold the suture. A suture retainer may be used in place of the second anchor. The passage may extend across a fracture in the bone. The passage may have either a nonlinear or linear configuration. A tubular member may be positioned in the passage with the tubular member extending into portions of the passage on opposite sides of the fracture. Opposite end portions of the tubular member may be disposed in a compact outer layer of the bone. If desired, a member other than a suture may be used as a force transmitting member between the two anchors. The tubular member may be formed of bone.

RELATED APPLICATION

This application is a continuation-in-part of U.S. patent applicationSer. No. 09/323,488, filed Jun. 1, 1999 by Peter M. Bonutti and entitled"Bone Suture". The aforementioned application Ser. No. 09/323,488 isitself a continuation of U.S. patent application Ser. No. 09/019,977filed Feb. 6, 1998 by Peter M. Bonutti and entitled "Bone Suture" (nowU.S. Pat. No. 5,921,986). The benefit of the earlier filing date of theaforementioned application Ser. Nos. 09/019,977 and 09/323,488 isclaimed for all subject matter common to the aforementioned applicationSer. Nos. 09/019,977 and 09/323,488 and this application.

BACKGROUND OF THE INVENTION

The present invention relates to a new and improved method and apparatusfor securing sections of a fractured bone and/or securing body tissue tobone.

When a bone is broken or fractured, it is necessary to press sections ofthe bone on opposite sides of the fracture together in order to promotehealing of the bone. Bone screws have been used with or without metalplates to hold the sections of the fractured bone against movementrelative to each other. In addition, it has been suggested that avulsionfractures could be treated by using wire sutures between sections ofbone in a matter similar to that disclosed in U.S. Pat. No. 5,474,554.It has also been suggested that an anchor could be retained in a bone isa manner disclosed in U.S. Pat. Nos. 5,527,343 and 5,534,012.

SUMMARY OF THE INVENTION

The present invention relates to a method of securing sections of afractured bone. Sections of a fractured bone are held against movementrelative to each other by a force transmitting member, such as a suture,which extends through a passage in the bone. The passage in the bone mayhave a linear or nonlinear configuration. Tension is maintained in theforce transmitting member to press surfaces on the fracture together bysecuring anchors and/or retainers to opposite ends of the forcetransmitting member. It is believed that a suture may advantageously beused as the force transmitting member.

A tubular member is positioned in a linear or nonlinear passage throughthe bone. The tubular member extends into portions of the passage onopposite sides of the fracture. End portions of the tubular member maybe positioned in a compact outer layer of the bone. The tubular membermay be formed of bone. The force transmitting member may be formed ofbone or other body tissue.

BRIEF DESCRIPTION OF THE DRAWINGS

The foregoing and other features of the invention will become moreapparent upon a consideration of the following description taken inconnection with the accompanying drawings wherein:

FIG. 1 is a schematic illustration of a bone having a fracture which hasbeen treated with sutures and suture anchors;

FIG. 2 is an enlarged fragmentary schematic sectional view of a portionof the bone of FIG. 1 and illustrating the manner in which a sutureextends across the fracture and interconnects suture anchors on oppositesides of the fracture;

FIG. 3 is a schematic illustration, generally similar to FIG. 2,illustrating the manner in which a suture retainer is used to maintaintension in a suture which extends across a fracture to a suture anchor;

FIG. 4 is a schematic illustration, generally similar to FIGS. 2 and 3,illustrating the manner in which body tissue is connected with a boneusing a suture and suture anchors;

FIG. 5 is a schematic illustration, generally similar to FIGS. 2-4,illustrating the manner in which a suture extends between suture anchorsthrough a nonlinear passage;

FIG. 6 is a schematic illustration, generally similar to FIG. 5,illustrating the manner in which a suture extends between a sutureanchor and a suture retainer through a nonlinear passage;

FIG. 7 is a schematic illustration depicting a bone which has beenfractured in such a manner as to have a bone fragment connected with thebone by muscle or other fibrous tissue;

FIG. 8 is a schematic illustration depicting the manner in which thebone fragment of FIG. 7 is connected to the bone by a suture and a pairof suture anchors;

FIG. 9 is a schematic illustration depicting the manner in which a bonefragment is connected with a bone by a suture which extends between ananchor within the bone and an anchor which engages the bone fragment;

FIG. 10 is a schematic illustration, generally similar to FIGS. 2-4 andillustrating in the manner in which plates and rigid fasteners are usedin association with a suture and anchors to treat a bone fracture;

FIG. 11 is a schematic illustration depicting the manner in which a thinelongated member is moved through bone and the manner in which a drillis moved along the thin elongated member to enlarge a passage formed inthe bone by the thin elongated member;

FIG. 12 is a schematic illustration depicting the manner in which ananchor is moved through a passage in the drill of FIG. 11 after the thinelongated member has been removed from the passage in the drill;

FIG. 13 is a schematic illustration, generally similar to FIG. 2,illustrating the manner in which a tubular member is positioned in apassage in the bone;

FIG. 14 is a schematic illustration, generally similar to FIG. 5,illustrating the manner in which tubular members are positioned in anonlinear passage in a bone; and

FIG. 15 is a schematic illustration, generally similar to FIG. 3,illustrating the manner in which a suture retainer is used with atubular member which is positioned in a passage in a bone.

DESCRIPTION OF SPECIFIC PREFERRED EMBODIMENTS OF THE INVENTION

A bone 20 which has been fractured is illustrated in FIG. 1. The bone 20is divided into two sections 22 and 24 by a fracture 26. Opposite sidesurfaces 28 and 30 of the fracture 26 are pressed together by bonesuture assemblies 32.

It should be understood that the bone suture assemblies 32 may beutilized in the treatment of any one of many different types offractures. The fractures may or may not result in the formation of oneor more bone fragments. In FIG. 1, the bone suture assemblies 32 havebeen illustrated as interconnecting sections 22 and 24 of a completebone fracture of the spiral type. However, the bone suture assemblies 32could be utilized to connect a fragment of a bone to the main portion ofthe bone from which the fragment was broken off.

Each of the bone suture assemblies 32 has the same construction.However, the bone suture assemblies 32 could have differentconstructions if desired. The construction of one of the identical bonesuture assemblies 32 is illustrated in FIG. 2.

The bone suture assembly 32 (FIG. 2) includes a flexible suture 38 whichextends across the fracture 26. The suture 38 is disposed in a straightcylindrical passage 40 which extends diametrically across a generallycylindrical portion of the bone 20. The passage 40 extends through hardcompact tissue of an outer layer 42 of the bone and through spongy orcancellous bone tissue 44 which is enclosed by the hard outer layer.Although the passage 40 has a linear configuration, the passage couldhave a nonlinear configuration if desired.

The suture 38 extends between a first suture anchor 50 disposed on oneside of the fracture 26 and a second suture anchor 52 disposed on theopposite side of the fracture. Tension is maintained in the suture 38 topress the suture anchors 50 and 52 against opposite sides of the bone 20with a predetermined force. This force presses the side surfaces 28 and30 of the fracture 26 firmly together to promote healing of thefracture. If desired, buttons or other force distributing members couldbe provided between the anchors 50 and 52 and the bone 20. Body tissuecould be disposed between the anchors 50 and 52 and the bone 20.

The suture 38 and/or suture anchors 50 and 52 may be formed of anydesired natural or artificial material. For example, the suture 38 mayformed of either a polymeric material or a metal. The suture 38 may bebiodegradable. Any known suture material may be utilized to form thesuture 38.

The suture anchors 50 and 52 have the same construction. However, theanchor 50 could have a construction which is different than theconstruction of the anchor 52. The anchor 50 has a cylindrical outerside surface 56 which extends between smooth rounded end portions 58 and60. A pair of parallel cylindrical openings 64 and 66 extenddiametrically through the anchor 50. The anchor 50 is free of sharpcorners or projections to avoid cutting or abrading of body tissuedisposed adjacent to the anchor.

The suture anchor 50 is made of a biocompatible material. Suitablematerials include stainless steel or titanium, cobalt chrome and otherbiocompatible metals. Polymeric material may also be used, suitablepolymeric materials includes polyethylene, polypropylene, andbiodegradable material such as PLA and PGA. It is believed that it maybe preferred to form the suture anchors 50 and 52 from biodegradable orbioerodible copolymers. If desired, the anchor 50 could be formed ofbody material or hydrophilic materials.

It is contemplated that the anchor 50 may have any desiredconfiguration. For example, the anchor 50 could have any one of theconfigurations disclosed in U.S. Pat. No. 5,522,846 issued Jun. 4, 1996and entitled "Suture Anchor". Alternatively, the suture anchor 50 couldhave the configuration disclosed in U.S. Pat. No. 5,534,012 issued Jul.9, 1996 and entitled "Method and Apparatus for Anchoring a Suture".

Although the anchor 50 may have any desired configuration, thecross-sectional size of the anchor is such as to enable the anchor to bemoved through the passage 40. In addition, the length of the anchor 50is such as to enable it to span an opening at an end of the passage 40and transmit force from the suture 38 to a substantial area on the outerlayer 42 of the bone 20. It is believed that it will be preferred toform the anchor 50 in such a manner as to eliminate any sharp corners orprojections.

In the illustrated embodiment of the invention, the anchor 50 has acylindrical configuration. This particular anchor has an axial length ofabout two millimeters and a diameter of about one millimeter. The lengthof the anchor 50 may be approximately three times the diameter of theanchor. The openings 64 and 66 have a diameter of about one-halfmillimeter.

It should be understood that the foregoing dimensions have been setforth herein for purposes of clarity of description and it iscontemplated that the size of the anchor 50 may vary as a function ofthe size of the bone being treated. Thus, relatively small anchors maybe used in association with treatment of small bones in a wrist, hand,foot or ankle of a patient. Relatively large anchors may be used inassociation with treatment of larger bones in an arm, shoulder, leg orhip of a patient. It should be understood that the bone suture assembly32 may be used in conjunction with many different bones other than thespecific bones previously mentioned.

Only a single anchor 50 or 52 has been shown at opposite ends of thepassage 40. It is contemplated that a plurality of anchors could beprovided at each end of the passage 40. For example, a pair of separateor interconnected anchors could be provided in a manner similar to thatdisclosed in the aforementioned U.S. Pat. No. 5,534,012.

In the embodiment of the invention illustrated in FIG. 2, the suture 38has a pair of limbs or sections 72 and 74 which extend through theopenings 64 and 66 in the suture anchors 50 and 52. A connector section76 interconnects the two limbs 72 and 74 of the suture 38 and engages aportion of the anchor 50. A knot 78 is formed in the opposite ends ofthe limbs 72 and 74 to interconnect the two limbs of the suture 38.

When the knot 78 is formed, a predetermined tension is present in thelimbs 72 and 74 of the suture 38. This results in the suture anchors 50and 52 being pressed firmly against the bone 20 with a predeterminedforce. This predetermined force is maintained during and after tying ofthe knot 78.

When the bone suture assembly 32 is to be used to treat the fracture 26in the bone 20, the two sections 22 and 24 of the bone are pressedtogether at the fracture 26 to align the side surfaces 28 and 30 of thefracture. A drill is then used to form the passage 40 which extendsdiametrically through the generally cylindrical bone 20. Of course, thepassage 40 could be formed by the use of a tool other than a drill. Ifdesired, the passage 40 could have a noncircular cross-sectionalconfiguration.

Once the passage 40 has been formed in the two sections 22 and 24 of thebone 20, a tubular cylindrical member is inserted into the passage 40and extends diametrically through the bone 20. The leading end of thetubular cylindrical member is aligned with a circular outlet 84 from thepassage 40. The opposite end of the tubular member is aligned with acircular inlet 86 to the passage 40. The tubular member has a thincylindrical wall which engages the sections 22 and 24 of the bone 20. Acylindrical inner side surface of the tubular member defines a passagehaving a diameter which is only slightly less than the diameter of thepassage 40.

By inserting the tubular member into the passage 40, the portions of thepassage disposed on opposite sides of the fracture 26 are maintained inalignment. The tubular member may be flexible to enable the tubularmember to be inserted into a nonlinear passage 40 through the bone 20.The tubular member may be formed of metal or a polymeric material. Ifthe tubular member is formed of a polymeric material, it may bepreferred to form the tubular member from a biodegradable or bioerodiblecopolymer.

The suture 38 is formed into a loop which extends through the openings64 and 66 in the anchor 50. At this time, the suture 38 has a lengthwhich is substantially greater than the length illustrated in FIG. 2.The cylindrical anchor 50, with the suture 38 connected thereto, is thenpositioned in axial alignment with the tubular member which extendsthrough the passage 40. Thus, the anchor 50 is moved to an orientationin which a longitudinal central axis of the anchor is coincident withthe longitudinal central axis of the cylindrical passage in the tubularmember which extends through the passage 40 in the bone 20.

The leading end 58 of the anchor 50 is then moved into the cylindricaltubular member which forms a liner for the passage 40. A pusher memberpushes the anchor 50 from an upper (as viewed in FIG. 2) end of thetubular member along the passage 40 in the bone 20 and through theoutlet 84 from the passage. As the anchor 50 moves through the passage40, the suture 38 is pulled through the passage 40 by the anchor.

The orientation of the anchor 50 is then changed from an orientation inwhich the longitudinal central axis of the anchor 50 is aligned with thelongitudinal central axis of the passage 40 to an orientation in whichthe longitudinal central axis of the anchor 50 extends generallyperpendicular to the longitudinal central axis of the passage 40, i.e.,the orientation shown in FIG. 2. To pivot the anchor 50 to theorientation shown in FIG. 2, as the anchor emerges from the outlet 84,the suture 38 is tensioned. The combination of the tension in the suture38 and force applied against the trailing end 60 of the anchor by thepusher member causes the anchor to pivot about the trailing end 60 ofthe anchor. The pusher member is then withdrawn and the suture tensionedto move the anchor to the position shown in FIG. 2 in a manner similarto that described in the aforementioned U.S. Pat. Nos. 5,527,343 and5,534,012.

Although it is believed that it may be preferred to change theorientation of the anchor 50 after it has emerged from the passage 40,the anchor could be blocked from reentering the passage in other ways ifdesired. Thus, the anchor could expand after emerging from the passage40. This could be accomplished by having spring biased arms held in aretracted position by engagement of spring biased arms with the innerside surface of the tubular cylindrical member which lines the passage40. Upon emerging from the passage, the arms would move outward underthe influence of spring forces and extend radially outward beyond theedge of the exit from the passage 40. If desired, the anchor 50 could beconstructed so as to expand in a manner similar to that disclosed inU.S. Pat. No. 5,397,331 and/or U.S. Pat. No. 4,409,974.

Rather than expanding under the influence of stored energy, such asspring force, the anchor 50 could expand by absorbing body fluids. Thus,the anchor 50 may be compressed when it moves through the passage 40 andwill expand and absorb body fluids after emerging from the passage 40.It is contemplated that the anchor 50 could be constructed so as toexpand in any one of the ways disclosed in U.S. patent application Ser.No. 08/699,553 filed Aug. 19, 1996 by Peter M. Bonutti and entitled"Suture Anchor".

The cylindrical tubular member is then withdrawn from the passage 40. Itshould be understood that the cylindrical tubular member is used to linethe passage 40 in the bone 20 during movement of the anchor 50 throughthe passage. The use of the tubular member to line the passage 40 may beomitted if desired. However, if the use of the tubular member to linethe passage 40 is omitted, the anchor 50 and pusher member would beexposed to the cancellous bone tissue 44 during movement of the anchorthrough the passage.

The limbs 72 and 74 of the suture 38 are then threaded through openings64 and 66 in the second suture anchor 52. The limbs 72 and 74 of thesuture 38 are tensioned and the second anchor 52 is pressed against theouter side surface of the bone 20. While a predetermined tension forceis maintained in the limbs 72 and 74 of the suture 38, the knot 78 istied in the suture to interconnect the two suture anchors 50 and 52 withthe suture 38. The suture 38 is then trimmed to the desired length.

Once the knot 78 has been tied between the limbs 72 and 74 of the suture38, the tension in the suture 38 presses the side surfaces 28 and 30 ofthe fracture 26 together. This pressure between the side surfaces 28 and30 of the fracture 26 is maintained by the suture 38 and suture anchors50 and 52 until the fracture heals. It is believed that it may bepreferred to form the suture 38 and suture anchors 50 and 52 of abiodegradable material which, after the fracture 26 has healed, willdissolve in the patient's body.

The cylindrical tubular member which is inserted into the passage 40through the bone 20 performs the dual functions of lining the inside ofthe passage 40 and maintaining the two sections 22 and 24 of the bone inalignment. The cylindrical tubular member could have a slot formed in aside wall of the tubular member to facilitate insertion of the tubularmember into the passage 40. It is contemplated that the cylindricaltubular member could be left in the passage 40 after the bone sutureassembly 32 has been installed. If the slotted or unslotted cylindricaltubular member is to be left in the passage 40, the cylindrical tubularmember may be formed of a biodegradable or bioerodible copolymer. Whenthe cylindrical tubular member remains in the passage 40, the suture 38extends through the tubular member.

Although only a knot 78 has been shown in FIG. 2 adjacent to the secondanchor 52, a suture retainer could be provided to further hold the limbs72 and 74 of the suture 38. If a suture retainer is to be used inassociation with the knot 78, the suture retainer will be moved alongthe limbs of the suture 38 toward the knot before the limbs 72 and 74 ofthe suture are trimmed to the short length shown in FIG. 2. The sutureretainer would then be plastically deformed to grip the limbs 72 and 74of the suture 38. Thereafter, the suture limbs 72 and 74 would betrimmed to a desired length.

Bone Suture Assembly--Second Embodiment

In the embodiment of the invention illustrated in FIG. 2, a pair ofsuture anchors 50 and 52 are connected with the suture 38 to maintaintension in the suture and pressure against opposite side surfaces 28 and30 of the fracture 26. In the embodiment of the invention illustrated inFIG. 3, a suture retainer is used in place of one of the suture anchors.Since the embodiment of the invention illustrated in FIG. 3 is generallysimilar to the embodiment of the invention illustrated in FIG. 2,similar numerals will be utilized to designate similar components, thesuffix letter "a" being associated with the embodiment of the inventionillustrated in FIG. 3 to avoid confusion.

A bone 20a has sections 22a and 24a which are separated by a fracture26a. The fracture 26a has side surfaces 28a and 30a which are pressedtogether by a bone suture assembly 32a. A suture 38a extends through acylindrical passage 40a which extends diametrically through thegenerally cylindrical bone 20a. The suture 38a has a pair of limbs orsections 72a and 74a which are connected with a suture anchor 50a. Thesuture anchor 50a has the same construction as the suture anchor 50 ofFIG. 2.

In accordance with a feature of this embodiment of the invention, asuture retainer 92 is used in place of the suture anchor 52 of FIG. 2.The suture retainer 92 has a spherical configuration. A cylindricalpassage 94 extends through the center of the spherical suture retainer92. The sections 72a and 74a of the suture 38a extend around thespherical outer side surface of the suture retainer 92. Thus, a loop isformed in each of the sections 72a and 74a around portions of the sutureretainer 92.

If desired, the suture retainer 92 could have a different configuration.For example, the suture retainer 92 could have an oval or ellipticalconfiguration. Although the passage 94 has a linear central axis, thepassage could have a nonlinear central axis. If desired, a plurality ofpassages having the same or different configurations could be providedin the suture retainer 92.

After the suture 38a has been inserted through the suture retainer 92,in the manner illustrated schematically in FIG. 3, the suture retainer92 is moved along the sections 72a and 74a of the suture 38a toward thebone 20a. The suture retainer 92 is formed as one piece of a polymericmaterial having a relatively low coefficient friction. Therefore, thetwo sections 72a and 74a of the suture 30a can readily slide along thesurfaces of the suture retainer 52a while the suture retainer movestoward the bone 20a.

A predetermined tension is maintained in the sections 72a and 74a of thesuture 38a while the suture retainer 92 is pressed against the bone 20a.This results in the suture 38a being pulled tightly against the sutureanchor 50a. The tension in the suture 38a is effective to press thesuture anchor 50a and retainer 92 against opposite sides of the bone 20awith a predetermined force.

Once the suture retainer 92 has been moved along the suture 38a and isbeing pressed against the bone 20a with a predetermined force, thesuture retainer is plastically deformed to grip the sections 72a and 74aof the suture 38a. An apparatus 98 for pressing the suture retainer 92against the bone 20a includes a tubular cylindrical plunger 102 (FIG. 3)having a cylindrical central passage through which the sections 72a and74a of the suture 38a extend. The plunger 102 is enclosed by a tubularcylindrical housing 106. The plunger 102 is pressed downward, relativeto the housing 106 with a predetermined force, indicated by arrows 108and 110 in FIG. 3. An annular transducer or load cell 114 provides anoutput indicative of the magnitude of the force 108 and 110 with whichthe suture retainer 92 is pressed against the bone 20a by the plunger102.

While the sections 72a and 74a of the suture 38a are being tensionedwith a predetermined force and while the plunger 102 is being pressedagainst the suture retainer 92 with a predetermined force, the sutureretainer 92 is plastically deformed. To plastically deform the sutureretainer 92, a plurality of force applying or clamp members 120 and 122are pressed against the suture retainer 92 with a predetermined minimumforce, indicated schematically by arrows 126 in FIG. 3. The forceapplication members 120 and 122 may have an arcuate configuration toconform to the spherical configuration of the suture retainer 92 or mayhave a flat configuration. The force applied against the suture retainer92 by the force applying members 120 and 122 is sufficient to causeplastic deformation of the material of the suture retainer.

The force 126 is applied against the suture retainer 92 while the sutureretainer is at a temperature which is below the transition temperatureof the biodegradable polymer which forms the suture retainer 92. Thus,the suture retainer 92 is at approximately the same temperature as thebone 20a when the force 126 is applied against the suture retainer. Theforce 126 causes the material of the suture retainer 92 to flow and gripthe sections 72a and 74a of the suture 38a.

Upon disengagement of the force application members 120 and 122 from thesuture retainer 92, the application of downward (as viewed in FIG. 3)force against the suture retainer 92 is interrupted. The upwardtensioning of the sections 72a and 74a of the suture 38a is alsointerrupted. At this time, the plastically deformed suture retainer 92securely grips the two sections 72a and 74a of the suture 38a tomaintain the tension in the suture 38a. If desired, a knot may be formedbetween the sections 72a and 74a of the suture as additional protectionagainst the suture working loose over an extended period of time.

The suture retainer 92 may be formed of many different materials.However, it is believed that it will be preferred to form the sutureretainer 92 of a biodegradable polymer. One biodegradable polymer whichmay be utilized is polycaperlactone. Alternatively, the suture retainer92 could be formed of polyethylene oxide terephthalate or polybutyleneterephthalate. It is also contemplated that other biodegradable orbioerodible copolymers could be utilized.

Although it is preferred to form the suture retainer 92 of abiodegradable material, the suture retainer could be formed of amaterial which is not biodegradable. For example, the suture retainer 92could be formed of an acetyl resin, such as "DELRIN" (trademark).Alternatively, the suture retainer 92 could be formed ofpara-dimethylamino-benzenediazo sodium sulfonate, such as "DEXON"(trademark). The construction of the suture retainer 92 and the mannerin which is cooperates with the suture 38a is the same as is disclosedin U.S. patent application Ser. No. 08/905,084 filed Aug. 1, 1997 byPeter M. Bonutti et al. and entitled "Method and Apparatus for Securinga Suture".

The suture retainer 92 is plastically deformed to grip the limbs 72a and74a of the suture 38a. However, the suture retainer 92 could beconstructed so as to be mechanically actuated to grip the suture 38a. Ifdesired, a combination of a mechanical gripping action and plasticdeformation could be utilized by a retainer to grip the suture 38a.

Retaining Body Tissue against Bone

In the embodiment of the invention illustrated in FIG. 2, a bone sutureassembly 32 is utilized to press surfaces 28 and 30 of a fracture 26together. In the embodiment of the invention illustrated in FIG. 4, thesuture anchor assembly is utilized to hold body tissue against movementrelative to a bone. Since the embodiment of the invention illustrated inFIG. 4 is generally similar to the embodiments of the inventionillustrated in FIGS. 2 and 3, similar numerals will be utilized inassociation with similar components, the suffix letter "b" beingassociated with the numerals of FIG. 4 to avoid confusion.

A cylindrical passage 40b extends diametrically through a generallycylindrical bone 20b. A bone suture assembly 32b is utilized to retainbody tissue 132 against movement relative to the bone 20b. The bodytissue 132 may be a muscle, ligament, cartilage or other tissue which isto be held against movement relative to the bone 20b.

The bone suture assembly 32b includes a first suture anchor 50b and asecond suture anchor 52b. A suture 38b extends through the passage 40band interconnects the suture anchors 50b and 52b. Tension in the suture38b presses the body tissue 132 against a side surface area on the bone20b. The suture 38b has sections or limbs 72b and 74b which extendsthrough openings in the suture anchors 50b and 52b in the mannerpreviously explained. A knot 78b interconnects the sections 72b and 74bof the suture 38b to press the suture anchor 52b firmly against the bodytissue 132. Although the illustrated suture has a pair of sections 72band 74b, the suture could have a single section if desired.

The suture anchor assembly 32b is installed in association with the bone20b and body tissue 132 in the same manner as previously explained inconjunction with the embodiment of the invention illustrated in FIG. 2.Thus, the passage 40 (FIG. 4) is formed in the bone 20b by drilling orother methods. The body tissue 132 may be offset to one side of thelocation where the passage 40b is formed during formation of thepassage. This enables the passage 40b to be formed in the bone 20bwithout damaging the body tissue 132.

The suture anchor 50b is moved through the passage 40b with alongitudinal central axis of the suture anchor aligned with thelongitudinal central axis of the passage 40b. When the suture anchor 50bemerges from the passage 40b, the anchor is pivoted to the orientationshown in FIG. 4. Alternatively, the anchor 50b may be mechanicallyexpanded after emerging from the passage 40b. A cylindrical tubularmember may be used to line the passage 40a during movement of the anchor50b through the passage in the manner previously described in connectionwith the embodiment of FIG. 2.

After the anchor 50b has been moved to the position shown in FIG. 4, thebody tissue 132 is positioned between the limbs 72b and 74b of thesuture 38b. The limbs 72b and 74b of the suture 38b are theninserted-through the openings in the suture anchor 52b. While apredetermined tension is maintained in the suture 38b, the knot 78b istied between the limbs 72b and 74b of the suture. This results in thebody tissue 132 being pressed against the bone 20b with a predeterminedforce. A button or other force distributing member may be providedbetween the suture anchor 52b and body tissue 132 if desired.

In the embodiment of the invention illustrated in FIG. 4, two sutureanchors 50b and 52b are utilized to press the body tissue 132 againstthe bone 20b. However, a suture retainer could be substituted for one ormore of the suture anchors 50b or 52b. For example, a suture retainerhaving the same construction and installed in the same manner as thesuture retainer 92 of FIG. 3 could be substituted for the anchor 52b ofFIG. 4. It should be understood that the suture retainer substituted forthe anchor 52b of FIG. 4 could have any desired construction. Thus, asuture retainer having the construction of any one of the sutureretainers disclosed in the aforementioned U.S. patent application Ser.No. 08/905,084, filed Aug. 1, 1997 by Peter M. Bonutti et al. andentitled "Method and Apparatus for Securing a Suture" could be utilizedin place of the anchor 52b and/or the anchor 50b.

When a suture retainer is used in place of the anchor 52b, the sutureretainer applies force against the body tissue 132 to press the bodytissue against the bone 20b. If desired, a force distribution membercould be provided between the suture retainer and the body tissue 132.

Although the passage 40b has been illustrated in FIG. 4 as having alinear configuration, the passage could have a nonlinear configurationif desired.

In the embodiment of the invention illustrated in FIG. 4, body tissue132 is disposed adjacent to only one side of the bone 20b. However, ifdesired, body tissue could be disposed adjacent to opposite sides of thebone 20b. The body tissue could be connected with the anchor 50b in manydifferent ways. For example, a separate length of suture could beconnected with the body tissue and anchor 50b or with the suture 38badjacent to the anchor 50b.

An alternative manner of connecting body tissue with the side of thebone adjacent to the anchor 50b would be to insert the body tissuebetween the limbs 72b and 74b of the suture 36b in the same manner asshown with the anchor 52b. If this is to be done, an end portion of thebody tissue may be manually inserted between the limbs 72b and 74b ofthe suture 38b. If a central portion of the body tissue is to bedisposed between the anchor 50b and the bone 20b, the connector section76b of the suture could be cut. One of the limbs 72b or 74b of thesuture would then be separated from the anchor 50b. The body tissuewould be inserted between the limbs of the suture 38. The separated endof the suture would then be inserted through the anchor 50b andconnected with the other limb of the suture 38b.

In the embodiment of the invention illustrated in FIG. 4, the bodytissue 132 is pressed against a bone 20b which has not been fractured.However, it is contemplated that the bone suture assembly 32 could beutilized to perform the dual functions of pressing body tissue against abone and of pressing opposite side surfaces of a fracture together. Thiswould result in the body tissue being pressed against the bone 20b inthe manner illustrated in FIG. 4 and in opposite side surfaces of afracture being pressed together in the manner illustrated in FIG. 2 forthe opposite side surfaces 28 and 30 of the fracture 26.

Nonlinear Suture Passage

In the embodiment of the invention illustrated in FIG. 2, the passage 40through which the suture 38 extends has a linear configuration. In theembodiment of the invention illustrated in FIG. 5, the passage throughwhich the suture extends has a nonlinear configuration. Since theembodiment of the invention illustrated in FIG. 5 is generally similarto the embodiment of the invention illustrated in FIGS. 2-4, similarnumerals will be utilized to identify similar components, the suffixletter "c" being associated with the components of the embodiment of theinvention illustrated in FIG. 5 to avoid confusion.

A bone 20c as a fracture 26c which divides the bone into two sections22c and 24c. Opposite side surfaces 28c and 30c of the fracture 26c arepressed together by a bone suture assembly 32c. The bone suture assembly32c includes a suture 38c which extends between first and second sutureanchors 50c and 52c.

In accordance with a feature of this embodiment of the invention, thesuture 38c is disposed in a passage 40c having a nonlinearconfiguration. Thus, the passage 40c includes a first section 140 whichis skewed relative to a second section 142 of the passage 40c. A bend144 is formed in the passage 40c at an intersection 146 of the first andsecond sections 140 and 142 of the passage 40c. The flexible suture 38cextends around the bend 144 along a nonlinear path between the sutureanchors 50c and 52c. At the bend 144, the suture 38c applies forceagainst the section 24c of the bone 20c urging the section 24c towardthe left (as viewed in FIG. 5). This force presses the sections 22c and24c of the bone 20c firmly together at the fracture 26c.

The suture anchors 50c and 52c have the same cylindrical construction asthe suture anchors 50 and 52 in the embodiment of the inventionillustrated in FIG. 2. A knot 78c (FIG. 5) is provided between limbs ofthe suture 38c to maintain a desired tension in the suture 38c. Thistension pulls the suture anchors 50c and 52c toward each other. Inaddition, this tension presses the section 24c of the bone 20c firmlyagainst the section 22c of the bone at the fracture 26c.

The first section 140 of the passage 40c is formed at an angle to andextends through a longitudinal central axis of the generally cylindricalbone 20c. The second section 142 of the passage 40c is formed in adirection perpendicular, i.e., along a radius, of the generallycylindrical bone 20c. The two sections 140 and 142 of the passage 40cterminate in the spongy cancellous bone tissue 44c.

When the suture assembly 32c is to be used to treat the fracture 26c inthe bone 20c, the two sections 22c and 24c of the bone are pressedtogether at the fracture 26c to align the side surfaces 28c and 30c ofthe fracture. A drill or other hole forming apparatus is then used toform the first section 140 of the passage 40c. The drill or other holeforming apparatus is then used to form the second section 142 of thepassage 40c. When the second section 142 of the passage 40c intersectsthe first section 140 of the passage 40c, formation of the section 142of the passage 40c is interrupted.

Once the nonlinear passage 40c has been formed in the two sections 22cand 24c of the bone 20c, a tubular cylindrical liner (not shown) isinserted into the passage 40c. The tubular cylindrical liner may beformed by two separate tubular members which are inserted at oppositeends of the passage 40c. Alternatively, the tubular cylindrical linermay be formed by a single flexible tubular member which is inserted intothe section 140 of the passage 40c and then moved around the bend 144into the section 142 of the passage 40c. It should be understood thatthe tubular cylindrical liner for the passage 40c could be omitted ifdesired.

The cylindrical anchor 50c, with the suture 38c connected thereto, isthen positioned in axial alignment with the section 142 of the passage40c. The leading end 58c of the anchor 50c is then moved into the linedsection 142 of the passage 40c. A flexible pusher member applies forceagainst the trailing end 60c of the anchor 50c and pushes the anchoraround the bend 144 and through the section 140 of the passage 40c.

Alternatively, a flexible wire or other member could be inserted intothe section 140 of the passage 40c. The wire would move around the bend144 and extend outward from the section 142 of the passage. The wirewould then be connected with the anchor 50c and suture 38c. The leadingend 58c of the anchor 50c would then be inserted into the section 142 ofthe passage 40c. Tension on the wire would pull the anchor 50c aroundthe bend 144 and out of the section 140 of the passage 40c.

Once the anchor 50c has been moved out of the passage 40c, the tubularliner for the passage may be withdrawn. If a one-piece tubular liner isused, it may be withdrawn from the open end of the section 142 of thepassage 40c. If a two-piece liner is used, one of the pieces may bewithdrawn from the open end of the passage section 140 and slit to clearthe suture 38c. Alternatively, the slit could be formed in the piece ofthe liner before it is inserted into the passage section 140. The otherpiece of the liner would be withdrawn from the open end of the passagesection 142. Alternatively, the tubular liner for the passage 40c may beleft in place. Of course, the use of a tubular liner for the passage 40cmay be omitted.

The suture 38c is then threaded through openings in the suture anchor52c. The suture 38c is then tensioned and the second anchor 52c ispressed against the outer side surface of the bone 20c. While apredetermined tension force is maintained in the suture 38c, the knot78c is tied.

In the illustrated embodiment of the invention, the two sections 140 and142 of the passage 40c have a straight cylindrical configuration.However, it is contemplated that the sections 140 and 142 of the passage40c could have a different configuration if desired. For example, thesection 140 and/or 142 of the passage 40c could have a nonlinear centralaxis and could have a noncircular cross-sectional configuration ofdesired.

Body tissue, corresponding to the body tissue 132 of FIG. 4 could bedisposed between the anchor 50c and/or 52c and the bone 20c. Althoughthe suture 38c has been illustrated as having a pair of limbs orsections which extend between the anchors 50c and 52c, the suture 38ccould have a single limb or section if desired. The anchor 50c couldmechanically expand, by absorbing body liquid or under the influence ofexpansion springs, after the anchor has emerged from the passage 40c toprevent the anchor from being pulled back through the passage.

Nonlinear Passage--Second Embodiment

In the embodiment of the invention illustrated in FIG. 5, the bonesuture assembly 32c associated with the nonlinear passage 40c includes apair of suture anchors 50c and 52c. In the embodiment of the inventionillustrated in FIG. 6, a suture retainer in substituted for one of thesuture anchors in much the same manner as previously described inconjunction with the embodiment of the invention illustrated in FIG. 3.Since the embodiment of the invention illustrated in FIG. 6 is generallysimilar to the embodiment of the invention illustrated in FIGS. 2-5,similar numerals will be utilized to designate similar components, thesuffix letter "d" being associated with the numerals of FIG. 6 in orderto avoid confusion.

A bone 20d has a fracture 26d which divides the bone into two sections22d and 24d. The fracture 26d has side surfaces 28d and 30d which arepressed together by a bone suture assembly 32d. The bone suture assembly32d includes a suture 38d which extends through a nonlinear passage 40dhaving the same construction as the nonlinear passage 40c of FIG. 5.

In accordance with a feature of this embodiment of the invention, thebone suture assembly 32d includes a suture anchor 50d having the sameconstruction as the suture anchor 50 of FIG. 2, and a suture retainer92d having the same construction as the suture retainer 92 of FIG. 3.The suture anchor 50d and suture retainer 92d maintain a predeterminedtension in the suture 38d. This results in the suture anchor 50d beingfirmly pressed against the section 24d of the bone 20d. The sutureretainer 92d is firmly pressed against the section 22d of the bone 20dby the tension in the suture 38d.

Since the passage 40d has a nonlinear configuration, the suture 38d iseffective to apply a force component to the section 24d of the bone 20durging the section 24d of the bone toward the left (as viewed in FIG.6). This results in the surface 30d of the fracture 26d being pressedfirmly against the surface 28d of the fracture.

The suture retainer 92d is plastically deformed to grip the suture 38din the same manner as previously described herein in conjunction withthe suture retainer 92 of FIG. 3. However, the suture retainer 92d couldbe constructed so as to form a mechanical connection with the suture38d. If desired, a suture retainer could be substituted for the anchor50d.

Although both the suture retainer 92d and anchor 50d have beenillustrated in FIG. 6 as being disposed in engagement with the bone 20d,a force distributing member could be provided between the anchor and/orsuture retainer and the bone. It is contemplated that body tissue,similar to the body tissue 132 of FIG. 4, could be disposed between theanchor 50d and/or the suture retainer 92d and the bone 20d.

Tissue Tensioning With Bone Fragment Retaining

In the embodiment of the invention illustrated in FIG. 2, the fracturein a portion of a bone is treated. In the embodiment of the inventionillustrated in FIGS. 7 and 8, a fracture results in a fragment of a bonebeing separated from a main portion of the bone. The bone fragment isconnected with the main portion of the bone by muscle, tendon, ligament,cartilage or other fibrous body tissue. In the embodiment of theinvention illustrated in FIGS. 7 and 8, the fibrous body tissue istensioned as the bone fragment is positioned relative to the mainportion of the bone. Since the embodiment of the invention illustratedin FIGS. 7 and 8 is generally similar to the embodiment of the inventionillustrated in FIGS. 2-6, similar numerals will be utilized to designatesimilar components, the suffix "e" being associated with the numerals ofFIGS. 7 and 8 in order to avoid confusion.

A bone fragment 154 is separate from a main bone 20e (FIG. 7). Thefragment 154 is connected with the main bone 20e by fibrous body tissue158, i.e., muscle, tendon, ligament, cartilage, etc. The fibrous bodytissue 158 extends between the bone fragment 154 and a portion 160 ofthe main bone 20e. The bone fragment 154 has a side surface 28e with aconfiguration which matches the configuration of a side surface 30e of afracture 26e which occurred in the main bone 20e.

In order to promote healing of the main bone 20e, a bone suture assembly32e (FIG. 8) is utilized to pull the bone fragment 154 toward the mainbone 20e. As this occurs, the fibrous body tissue 158 is tensioned andthe side surface 28e on the bone fragment 154 is pressed against theside surface 30e on the main bone 20e. The bone fragment 154 is pressedfirmly against the main bone 20e by the bone suture assembly 32e. Thus,the gap illustrated schematically in FIG. 8, between the side surfaces28e and 30e of the fracture 26e, is eliminated and the side surfaces ofthe fracture are pressed firmly together by the bone suture assembly32e. If desired, the bone fragment 154 may be manually pressed againstthe main bone 20e before the bone suture assembly is pulled tight.

The bone suture assembly 32e includes a suture 38e having limbs orsections 72e and 74e. The suture 38e extends through openings in a firstsuture anchor 50e. The suture then extends into a passage 40e formed inthe bone fragment 154 and the main bone 20e.

The passage 40e includes a first section 140e which extends through thebone fragment 154. In addition, the passage 40e includes a secondsection 142e which extend through the main bone 20e. The limbs orsection 72e and 74e of the suture 38e extends through a second anchor52e.

During installation of the bone suture assembly 32e, the limbs 72e and74e of the suture 38e are gripped by a force or tension measurementdevice 98e. The tension measurement device 98e includes a load cellwhich measures the amount of tension applied to the limbs 72e and 74e ofthe suture 38e.

As tension is applied to the limbs 72e and 74e of the suture 38e, thebone fragment 154 is pulled toward the right (as viewed in FIG. 8) tomove the side surface 28e on the bone fragment into alignment with theside surface 30e on the main bone 20e. As this occurs, the fibrous bodytissue 158 is stretched or tensioned. While a predetermined force istransmitted through the limbs 72e and 74e to the suture anchor 50e andthe bone fragment 154 to firmly press the bone fragment against the mainbone 20e, a knot 78e is tied to interconnect the limbs 72e and 74e.While the predetermined tension is maintained and the knot 78e tied, thesecond anchor 52e is firmly pressed against the side surface of the mainbone 20e.

Although the passage 40e could have a linear configuration if desired,in the embodiment of the invention illustrated in FIG. 8, the passage40e has a nonlinear configuration. Thus, the first section 140e of thepassage 40e has a central axis which is skewed relative to a centralaxis of the second section 142e of the passage 40e. This enables theflexible suture 38e to apply force to the bone fragment 154 havingcomponents urging the bone fragment rightward (as viewed in FIG. 8)against the surface 30e on the main bone 20e and downward (as viewed inFIG. 8) to maintain the tension in the fibrous body tissue 158.

When the passage 40e is to be formed in the bone fragment 154 and mainbone section 20e, a hole is drilled through the bone fragment 154 toform the first section 140e of the passage. The second portion 142e ofthe passage 40e is drilled in the main bone 20e. It should be understoodthat the passage 40e could be formed in many different ways other thandrilling. For example, a cutting tool or laser could be used to form thepassage 40e.

The second section 142e of the passage 40e has a longitudinal centralaxis which is skewed at an acute angle relative to the longitudinalcentral axis of the first section 140e of the passage in the bonefragment 154. Thus, the first portion 140e of the passage 40e in thebone fragment 154 has a central axis which is close to beingperpendicular to a longitudinal central axis of the main bone 20e. Thesecond portion 142e of the passage 40e has a longitudinal central axiswhich is angularly offset to a substantial arc relative to thelongitudinal central axis of the main bone 20e.

The anchor 50e is moved through the first section 140e of the passage40e and positioned in engagement with an outer side surface of the bonefragment. The free ends of the limbs 72e and 74e of the suture 38e arethen moved rightward (as viewed in FIG. 8) through the second portion142e of the passage 40e. The free ends of the suture 38e are thenthreaded through openings in the second anchor 52e.

After the suture 38e has been inserted through openings in the secondanchor 52e, the force or tension measuring device 98e is utilized topull the free ends of the suture 38e toward the right (as viewed in FIG.8). This tension pulls the bone fragment 154 into engagement with themain bone 20e. The knot 78e is tied in the free ends of the suture 38ewhile the tension is maintained in the suture.

If desired, the bone suture assembly 32e could be positioned relative tothe bone 20e and the bone fragment 154 by moving the anchor 50e firstthrough the second section 142e of the passage disposed in the main bone20e and then through the first section 140e of the passage disposed inthe fragment 154. The free ends of the suture would then be insertedthrough the second anchor 52e. The suture 38e would be tensioned to pullthe bone fragment 154 into place with the side surface 28e in alignedengagement with the surface 30e on the main bone 20e. The knot 78e wouldthen be tied while maintaining the desired tension in the suture 38e.

It should be understood that the anchor 52e and knot 78e could bepositioned adjacent to the bone fragment 154 and the anchor 50epositioned adjacent to the bone 20e. Although only a single bone sutureassembly 32e has been illustrated in FIG. 8, multiple bone sutureassemblies could be used to position the bone fragment 154 relative tothe bone 20e.

In the embodiment of the invention illustrated in FIGS. 7 and 8, thebone suture assembly 32e includes a pair of anchors 50e and 52e. Ifdesired, a suture retainer could be substituted for either or both ofthe anchors 50e and 52e. Thus, a suture retainer having a constructionsimilar to the construction of the suture retainer 92 of FIG. 3 could beused in place of the second anchor 52e. It should be understood that thesuture retainer 92 could have the same construction as any one of thesuture retainers disclosed in the aforementioned U.S. patent applicationSer. No. 08/905,084 filed Aug. 1, 1997 by Peter M. Bonutti et al. andentitled "Method and Apparatus for Securing a Suture".

In the embodiment of the invention illustrated in FIG. 8, the anchors50e and 52e are placed in engagement with the bone of fragment 154 andmain bone 20e. However, it is contemplated that the anchor 50e and/or52e could be positioned in engagement with body tissue other than bone.For example, the anchor 50e could be positioned in engagement with aportion of the fibrous body tissue 158 to position the fibrous bodytissue 158 relative to the bone fragment 154 and to more securelyinterconnect the fibrous body tissue and the bone fragment. If desired,body tissue could be positioned between the anchor 52e and the main bone20e.

In FIG. 8, there is a single bone fragment 154. However, fractures mayoccur in such a manner as to have a plurality of bone fragments. Aplurality of bone suture assemblies 32e could be utilized tointerconnect the plurality of bone fragments and the main bone.

When a fracture occurs in such a manner as to form a plurality of bonefragments, it may be desired to use bone suture assemblies 32e inassociation with only the larger bone fragments. If desired, a bridge orcover member could extend across the bone fragments to position the bonefragments relative to each other. One or more bone suture assemblies 32ewould extend through one or more of the larger bone fragments andthrough the bridge or cover member. Force applied against the bridge orcover member by an anchor or anchors in a bone suture assembly orassemblies 32e would urge the bridge or cover member toward the mainbone 20e to position the smaller bone fragments relative to the largerbone fragments and main bone 20e and to press the bone fragments againsteach other and against the main bone.

One or more of the anchors 50e and 52e could be formed of body tissue orof material which absorbs body fluid and expands. Alternatively, one ormore of the anchors 50e or 52e could be mechanically expanded to blockmovement into the passage 50e.

Bone Fragment Retention

In the embodiment of the invention illustrated in FIG. 2, the bonesuture assembly 32 extends between diametrically opposite outer sidesurface areas on the bone 20. This results in the first suture anchor 50being disposed against an outer side surface of the hard outer layer 42of the bone 20 (FIG. 1) and the suture anchor 52 being disposed againstthe outer side surface of the hard outer layer 42 on the opposite sideof the bone. In the embodiment of the invention illustrated in FIG. 9,one of the anchors is disposed within the bone and the other anchor isdisposed outside of the bone. Since the embodiment of the inventionillustrated in FIG. 9 is generally similar to the embodiment of theinvention illustrated in FIGS. 2-8, similar numerals will be utilized toidentify similar components, the suffix letter "f" being associated withthe numerals of FIG. 9 in order to avoid confusion.

A bone 20f has a hard outer layer 42f which encloses spongy cancellousbone tissue 44f. A fragment 164 has broken away from the hard outerlayer 42f. A bone suture assembly 32f is used to position and hold thefragment 164 in engagement with the bone 20f. The bone suture assembly32f includes a first suture anchor 50f which is disposed in engagementwith an inner side surface 166 of the outer layer 42f of bone. A secondanchor 50f is disposed in engagement with an outer side surface 168 ofthe fragment 164. A suture 38f extends between the first and secondanchors 50 and 52f. The suture 38f extends through a passage 40f whichextends across a fracture 26f.

When the bone suture assembly 32f is used to position the fragment 164against the outer layer 42f of the bone 20f, the fragment 164 is alignedwith the outer layer 42f of the bone 20f. At this time, a side surface172 on the fragment 164 is disposed in aligned engagement with a sidesurface 174 on the bone 20f. The two side surfaces 172 and 174 wereformed by breaking away of the fragment 164 from the outer layer 42f ofthe bone.

Once the fragment 164 has been aligned with the bone 20f, the linearpassage 40f is formed by drilling or other methods through the fragment164 and the outer layer 42f of bone. A cylindrical tubular member (notshown) having a thin cylindrical side wall is then inserted through thepassage 40f. The first anchor 50f is moved to an orientation in which alongitudinal central axis of the first anchor is aligned with alongitudinal central axis of the cylindrical tubular member.

The first anchor 50f is then moved through the cylindrical tubularmember, across the fracture 26f and into the spongy cancellous bonetissue 44. A pusher member applies force against a trailing end of afirst anchor 50f to push the anchor through the tubular member. When theleading end of the first anchor 50f emerges from the passage 40f, thelongitudinal central axis of the first anchor is aligned with thelongitudinal central axis of the passage 40f.

The first anchor 50f is then pivoted through 90 ° to change itsorientation to the orientation shown in FIG. 9. The tubular member isthen withdrawn from the passage 40f. The free ends of the suture 38f arethen inserted through openings in the anchor 52f. The suture istensioned to press the anchor 50f against the inner side surface 166 onthe outer layer 42f of the bone 20f. The second anchor 52f is pressedagainst the outer side surface 168 or the fragment 164 with apredetermined force by the tension in the suture 38f. A knot 78f is thentied in the free ends of the suture 38f to maintain the desired tensionin the suture.

Although it is believed that it may be desired to remove the tubularmember from the passage 40f, the tubular member could be left in thepassage if desired. If the tubular member is to be left in the passage40f, the tubular member may be formed of a biodegradable or bioerodiblecopolymer. Of course, the use of the tubular member could be eliminatedif desired.

It should be understood that a suture retainer, having a constructionsimilar to the construction of the suture retainer 92 of FIG. 3, couldbe used in place of the second anchor 52f if desired. Although thesuture anchor 52f has been shown in FIG. 9 as being disposed in directabutting engagement with the outer side surface 168 of the bone fragment164, a layer of body tissue could be provided between the suture anchor52f and the outer side surface 168 of the bone fragment 164 to hold thebody tissue against movement relative to the bone 20f. If desired, aplurality of bone suture assemblies 32f could be utilized to hold thebone fragment 164.

Use of Plates with Bone Suture Assembly

In the embodiment of the invention illustrated in FIG. 2, the sutureanchors 50 and 52 are disposed in abutting engagement with an outer sidesurface of a bone. In the embodiment of the invention illustrated inFIG. 10, a pair of bone plates and rigid fasteners are used inassociation with a bone suture assembly. Since the embodiment of theinvention illustrated in FIG. 10 is generally similar to the embodimentof the invention illustrated in FIGS. 2-9, similar numerals will beutilized to designated similar components, the suffix "g" beingassociated with the numerals of FIG. 10 to avoid confusion.

A bone 20g has sections 22g and 24g which are separated by a fracture26g. In accordance with a feature of this embodiment of the invention, apair of plate members 184 and 186 are used in association with a bonesuture assembly 32g. The plate members 184 and 186 may be formed of anydesired biocompatible material. Thus, the plate members may be formed ofmetal or a polymeric material. If the plate members 184 and 186 areformed of polymeric material, biodegradable or bioerodible copolymerscould be utilized.

In the illustrated embodiment of the invention, the plate members 184and 186 are rigid and are shaped to engage the bone 20g. If desired, theplate members 184 and 186 could have sufficient flexibility to enablethe plate members to be plastically deformed to the configuration of thebone 20g after having been positioned in engagement with the bone.

A first suture anchor 50g is pressed against the plate member 184 bytension in a suture 38g. The suture 38g extends through a passage 40g inthe bone 20g. A second anchor 52g is pressed against the plate member186 by the tension in the suture 38g. A knot 78g is provided in thesuture 38g.

A pair of screws 190 and 192 extend diametrically through the bone 20gbetween the plate members 184 and 186. The screws 190 and 192 areengaged by nuts 196 and 198 which engage the plate member 184. Thescrews 190 and 192 and nuts 196 and 198 cooperate to press the platemembers 184 and 186 against the bone 20g. If desired, bone sutureassemblies having the same construction as the bone suture assembly 32gcould be substituted for the screws 190 and 192 and nuts 196 and 198 sothat the plates 184 and 186 would be held in position against the bone20g by only the plurality of bone suture assemblies 32g.

The screws 190 and 192 and nuts 196 and 198 may be formed of any desiredbiocompatible material. Thus, the screws 190 and 192 and nuts 196 and198 may be formed of metal or a polymeric material. If the screws 190and 192 and nuts 196 and 198 are formed of polymeric material,biodegradable or bioerodible copolymers could be utilized.

In the illustrated embodiment of the invention, the screws 190 and 192extend through the bone 20g. It is contemplated that shorter screwscould be utilized if desired. These shorter screws would have relativelycoarse bone engaging thread convolutions to hold the short screws andplate members 184 and 186 in place. The shorter screws would have alength which is less than diameter of the bone 20g.

In the illustrated embodiment of the invention, the bone suture assembly32g extends through a linear passage 40g. If desired, the passage 40gcould have a nonlinear configuration. If bone suture assemblies 32g aresubstituted for the screws 190 and 192 and nuts 196 and 198, some of thebone suture assemblies could extend through linear passages while otherbone suture assemblies extend through nonlinear passages.

Installation Method

In the embodiment of the invention illustrated in FIG. 2, the passage 40is formed in the bone 20 by any desired method. A thin walledcylindrical tubular member is then inserted into the passage and thefirst suture anchor 50 moved through the thin walled member. In theembodiment of the invention illustrated in FIGS. 11 and 12, a cannulateddrill is used to drill a passage through a bone and to guide movement ofthe first anchor through the bone. Since the embodiment of the inventionillustrated in FIGS. 11 and 12 is generally similar to the embodimentsof the invention illustrated in FIGS. 2-10, similar numerals will beutilized to identify similar components, the suffix "h" being associatedwith the numerals in FIGS. 11 and 12 to avoid confusion.

A bone 20h has a fracture (not shown). When the fracture is to betreated with a bone suture assembly 32h (FIG. 12), a thin elongatedcylindrical member or K-wire 204 is first inserted through the bone 20h.This may be done by rotating the thin elongated member 204 with a drilldrive mechanism in the manner indicated by an arrow 206 in FIG. 11. Thedrill drive mechanism is provided with a passage which extends through adrive shaft for the mechanism. While the thin elongated member 204 isbeing rotated by the drill drive mechanism, the K-wire extends throughthe passage in the drill drive mechanism.

As the thin elongated member 204 is rotated by the drill drivemechanism, it is pressed against the bone 20h. As the thin elongatedmember 204 is rotated, in the manner indicated by the arrow 206 in FIG.11, the thin elongated member is moved diametrically through thegenerally cylindrical bone 20h until the leading end of the thinelongated member 204 extends from the opposite side of the bone. Thus,the thin elongated member 204 is moved through the hard outer layer 42h(FIG. 12) at one side of the bone 20h, through the spongy or cancellousbone tissue 44h, and through the hard outer layer at the diametricallyopposite side of the bone. When this has been done, the thin elongatedmember 204 will extend across the fracture in the bone.

The drill drive mechanism is then disengaged from the thin elongatedmember 204. A cannulated drill 210 is moved axially along the thinelongated member until the leading end portion 212 of the drill 210engages the bone 20h (FIG. 11). The drill 210 is then gripped by thedrill drive mechanism.

While the thin elongated member 204 remains stationary, the drill 210 isrotated about the thin elongated member in the manner indicated by anarrow 214 in FIG. 11. As the drill 210 is rotated about the stationarythin elongated member 204, the drill is moved axially into the bone 20h.As this occurs, the leading end 212 of the drill enlarges the hole orpassage formed in the bone 20h by the thin elongated member 204. Thedrill 210 is moved along the thin elongated member 204 until the drillextends diametrically across the bone 20h. This movement of the drill210 is guided by engagement of the thin elongated member 204 with a sidewall of a cylindrical passage 218 which extends axially through thedrill 210. Movement of the drill 210 through the bone 20h forms apassage 40h which extends through a fracture in the bone.

Once the drill 210 has been moved diametrically through the generallycylindrical bone 20h (FIG. 12), the thin elongated member 204 iswithdrawn from the drill. This leaves an open cylindrical passage 218extending through the drill 210 and across the bone 20h. The passage 218has a diameter which is just slightly greater than the diameter of acylindrical first anchor 50h of the bone suture assembly 32h. Thecylindrical first anchor 50h is axially aligned with the passage 218 inthe drill 210, in the manner shown in FIG. 12. At this time, the suture38h has been inserted through openings in the first anchor 50h andsuture limbs or sections 72h and 74h extend away from the first anchor50h, in the manner indicated schematically in FIG. 12.

A cylindrical pusher member 222 is axially aligned with the first anchor50h and the passage 218 through the drill 210. The pusher member 222 isutilized to push the first anchor 50h through the drill 210 to the farside of the bone 20h.

As the first suture anchor 50h emerges from the passage 28 in the drill210, the anchor is pivoted through ninety degrees. This pivotal movementchanges the orientation of the anchor 50h from an orientation in whichthe longitudinal central axis of the anchor 50h is aligned with thelongitudinal central axis of the passage 218 and drill 210 to anorientation in which a longitudinal central axis of the cylindricalanchor 50h extends perpendicular to the longitudinal central axis of thepassage and drill. The manner in which the anchor 50h is pivoted is thesame as is described in the aforementioned U.S. Pat. Nos. 5,527,343 and5,534,012.

The pusher member 222 is then withdrawn from the drill 10 and the drillis withdrawn from the passage formed through the bone 20h. As thisoccurs, the suture 38h is tensioned to hold the anchor 50h in placeagainst the bone 20h. The drill 210 is then disengaged from the suture38h. The free limbs 72 and 74 of the suture 38h are then insertedthrough a second anchor corresponding to the anchor 52 in FIG. 2. Whilea predetermined tension is maintained in the suture 38h, the suture istied to hold the second suture anchor, corresponding to the sutureanchor 52 in FIG. 2, against the bone 20h on a side of the bone oppositefrom the anchor 50h.

In the foregoing description, the drill 210 has been a rigid drill whichhas been used to form a linear passage to the bone 20h. However, it iscontemplated that a flexible drill could be utilized to drill a passagethrough the bone. If this was done, the drill could be guided in such amanner as to form a nonlinear passage in the bone.

The foregoing description of how the passage 40h is formed has been inconjunction with a bone 20h having a fracture similar to the fracture 26of FIG. 2. However, it is contemplated that the thin elongated member204 and drill 210 could be used to form a passage in a bone which hasnot been fractured (FIG. 4). The thin elongated member 204 and 210 couldbe used to form a passage which extends only part way through a bone(FIG. 9).

In the description of the embodiments of the invention illustrated inFIGS. 1-12, the suture 38 (FIG. 2) has a pair of limbs or sections 72and 74. It is contemplated that the suture 38 could have only a singlelimb which would be connected at one end with the first anchor 50 and atthe opposite end with the second anchor 52. This single limb couldeither be tied off at the second anchor 52 or gripped by a sutureretainer, similar to the suture retainer 92 of FIG. 3.

In the embodiments of the invention illustrated in FIGS. 112, the suture38 has been formed separately from the first suture anchor 50. It iscontemplated that the first suture anchor 50 could be formed as onepiece with the suture 38. For example, the suture and anchor could beformed as one piece in a manner similar to that disclosed in U.S. Pat.No. 4,669,473 or in U.S. Pat. No. 4,741,330.

The anchors 50 and 52 in the embodiment of FIGS. 2-12 could have any oneof many different constructions. For example, the anchors could expandby absorbing body fluid. The anchor 50, which is moved through a passage40 in the embodiments of FIGS. 2-12, could mechanically expand uponexiting from the passage.

Positioning of Tubular Member

In the embodiment of the invention illustrated in FIG. 13, a tubularmember is positioned in the passage which extends through the bone.Since the embodiment of the invention illustrated in FIG. 13 isgenerally similar to the embodiments of the invention illustrated inFIGS. 1-12, similar numerals will be utilized to designate similarcomponents, the suffix letter "j" being associated with the numerals ofFIG. 13 to avoid confusion.

A bone 20j which has been fractured is illustrated in FIG. 1. The bone20j is divided into two sections 22j and 24j by a fracture 26j. Oppositeside surfaces 28j and 30j of the fracture 26j are pressed together bybone securing assemblies 32j.

It should be understood that the bone securing assemblies 32j may beutilized in the treatment of any one of many different types offractures. The fractures may or may not result in the formation of oneor more bone fragments. In FIG. 13, the bone securing assembly 32j hasbeen illustrated as interconnecting sections 22j and 24j of a completebone fracture of the spiral type. However, the bone securing assemblies32j could be utilized to connect a fragment of a bone to the mainportion of the bone from which the fragment was broken off.

The bone securing assembly 32j (FIG. 13) includes a force transmittingmember 38j which extends across the fracture 26j. The force transmittingmember 38j may be any one of many different types of force transmittingmembers. The force transmitting member 38j may be formed of human oranimal body tissue. However, it is presently preferred to use a sutureas the force transmitting member 38j. Therefore, the force transmittingmember 38j will be referred to herein as a suture.

The suture 38j, that is, the force transmitting member, is disposed in astraight cylindrical passage 40j which extends diametrically across agenerally cylindrical portion of the bone 20j. The passage 40j extendsthrough hard compact tissue of an outer layer 42j of the bone andthrough spongy or cancellous bone tissue 44j which is enclosed by thehard outer layer. Although the passage 40j has a linear configuration,the passage could have a nonlinear configuration if desired.

The suture 38j extends between a first suture anchor 50j disposed on oneside of the fracture 26j and a second suture anchor 52j disposed on theopposite side of the fracture. Tension is maintained in the suture 38jto press the suture anchors 50j and 52j against opposite sides of thebone 20j with a predetermined force. This force presses the sidesurfaces 28j and 30j of the fracture 26j firmly together to promotehealing of the fracture. If desired, buttons or other force distributingmembers could be provided between the anchors 50j and 52j and the bone20j. Body tissue could be disposed between the anchors 50j and 52j andthe bone 20j.

The suture 38j and/or suture anchors 50j and 52j may be formed of anydesired natural or artificial material. For example, the suture 38j maybe formed of either a polymeric material or a metal. The suture 38j maybe biodegradable. Any known suture material may be utilized to form thesuture 38j.

The suture anchors 50j and 52j have the same construction. However, theanchor 50j could have a construction which is different than theconstruction of the anchor 52j. The anchor 50j has a cylindrical outerside surface 56j which extends between smooth rounded end portions 58jand 60j. A pair of parallel cylindrical openings 64j and 66j extenddiametrically through the anchor 50j. The anchor 50j is free of sharpcorners or projections to avoid cutting or abrading of body tissuedisposed adjacent to the anchor.

The suture anchor 50j is made of a biocompatible material. Suitablematerials include stainless steel or titanium, cobalt chrome and otherbiocompatible metals. Polymeric material may also be used, suitablepolymeric materials includes polyethylene, polypropylene, andbiodegradable material such as PLA and PGA. It is believed that it maybe preferred to form the suture anchors 50j and 52j from biodegradableor bioerodible copolymers. If desired, the anchor 50j could be formed ofbody material or hydrophilic materials.

It is contemplated that the anchor 50j may have any desiredconfiguration. For example, the anchor 50j could have any one of theconfigurations disclosed in U.S. Pat. No. 5,522,846 issued Jun. 4, 1996and entitled "Suture Anchor". Alternatively, the suture anchor 50j couldhave the configuration disclosed in U.S. Pat. No. 5,534,012 issued Jul.9, 1996 and entitled "Method and Apparatus for Anchoring a Suture".

The cross-sectional size of the anchor 50j may be such as to enable theanchor to be moved through the passage 40j. However, the anchor 50jcould have a size and configuration which would prevent movement of theanchor 50j through the passage 40j. For example, the anchors 50j and 52jcould have the same construction as the retainer 92 of FIG. 3.

The length of the anchor 50j is such as to enable it to span an openingat an end of the passage 40j and transmit force from the suture 38j to asubstantial area on the outer layer 42j of the bone 20j. The length ofthe anchor 50j may be approximately three times the diameter of theanchor. It is believed that it will be preferred to form the anchor 50jin such a manner as to eliminate any sharp corners or projections.

In the illustrated embodiment of the invention, the anchor 50j has acylindrical configuration. This particular anchor has an axial length ofabout two millimeters and a diameter of about one millimeter. Theopenings 64j and 66j have a diameter of about one-half millimeter.

It should be understood that the foregoing dimensions have been setforth herein for purposes of clarity of description and it iscontemplated that the size of the anchor 50j may vary as a function ofthe size of the bone being treated. Thus, relatively small anchors maybe used in association with treatment of small bones in a wrist, hand,foot or ankle of a patient. Relatively large anchors may be used inassociation with treatment of larger bones in an arm, shoulder, leg orhip of a patient. It should be understood that the bone securingassembly 32j may be used in conjunction with many different bones otherthan the specific bones previously mentioned.

Only a single anchor 50j or 52j has been shown at opposite ends of thepassage 40j. It is contemplated that a plurality of anchors could beprovided at each end of the passage 40j. For example, a pair of separateor interconnected anchors could be provided in a manner similar to thatdisclosed in the aforementioned U.S. Pat. No. 5,534,012.

In the embodiment of the invention illustrated in FIG. 13, the suture38j has a pair of limbs or sections 72j and 74j which extend through theopenings 64j and 66j in the suture anchors 50j and 52j. A connectorsection 76j interconnects the two limbs 72j and 74j of the suture 38jand engages a portion of the anchor 50j. A knot 78j is formed in theopposite ends of the limbs 72j and 74j to interconnect the two limbs ofthe suture 38j.

When the knot 78j is formed, a predetermined tension is present in thelimbs 72j and 74j of the suture 38j. This results in the suture anchors50j and 52j being pressed firmly against the bone 20j with apredetermined force. This predetermined force is maintained during andafter tying of the knot 78j.

When the bone securing assembly 32j is to be used to treat the fracture26j in the bone 20j, the two sections 22j and 24j of the bone arepressed together at the fracture 26j to align the side surfaces 28j and30j of the fracture. A drill is then used to form the passage 40j whichextends diametrically through the generally cylindrical bone 20j. Ofcourse, the passage 40j could be formed by the use of a tool other thana drill. If desired, the passage 40j could have a noncircularcross-sectional configuration.

Once the passage 40j has been formed in the two sections 22j and 24j ofthe bone 20j, a tubular cylindrical member 240 is inserted into thepassage 40j and extends diametrically through the bone 20j. The leadingend 242 of the tubular cylindrical member 240 is aligned with a circularoutlet 84j from the passage 40j. The opposite or trailing end 244 of thetubular member is aligned with a circular inlet 86j to the passage 40j.The tubular member 240 has a thin cylindrical wall which engages thesections 22j and 24j of the bone 20j. A cylindrical inner side surfaceof the tubular member 240 defines a cylindrical passage having adiameter which is only slightly less than the diameter of the passage40j.

The leading end 242 of the tubular member 240 is disposed in the compactouter layer 42j of the bone 20j. Similarly, the trailing end 244 of thetubular member 240 is disposed in the compact outer layer 42j of thebone 20j. The tubular member 240 extends across the fracture 26j andstabilizes the two sections 22j and 24j of the bone 20j. Since theopposite end portions of the tubular member 240 are disposed in thecompact outer layer 42j of the bone 20j, the tubular member is solidlysupported and holds the two sections 22j and 24j of the bone 20j inalignment at the fracture 26j.

The opposite ends 242 and 244 of the tubular member 240 are axiallyspaced from a generally cylindrical outer side surface 250 on the bone20j. This enables the anchors 50j and 52j to be pressed against theouter side surface 250 of the bone 20j. Therefore, tension forces in thesuture 38j are transmitted through the anchors 50j and 52j to the bone20j.

By inserting the tubular member 240 into the passage 40j, the portionsof the passage disposed on opposite sides of the fracture 26j aremaintained in alignment. The tubular member 240 may be flexible toenable the tubular member to be inserted into a nonlinear passage 40jthrough the bone 20j. The tubular member 240 may be formed of metal or apolymeric material. If the tubular member 240 is formed of a polymericmaterial, it may be preferred to form the tubular member from abiodegradable or bioerodible copolymer.

In accordance with one of the features of this embodiment of theinvention, the tubular member 240 is formed of bone. By forming thetubular member 240 of bone, tissue growth into the tubular member ispromoted. The tubular member 240 may be packed with bone or bone graft.The tubular member 240 may contain bone osteoinductive protein (BMP).Bone growth inducing materials containing apatite compositions withcollagen and/or other materials may be utilized. The tubular member 240may be formed of either human or animal bone.

It is contemplated that it may be preferred to form the tubular member240 of freeze dried human bone obtained from a cadaver. The freeze driedbone will absorb body fluids. As this occurs, the tubular member 240will expand and grip the two sections 22j and 24j of the bone 20j. Thebody fluids will be conducted into bone growth promoting materialscontained in the tubular member 240. If desired, antibiotics and/orother medicants may be provided in the bone or bone graft with which thetubular member 240 is packed. Of course, the tubular member 240 may beformed of other materials, such as biodegradable materials, if desired.

The suture 38j is formed into a loop which extends through the openings64j and 66j in the anchor 50j. At this time, the suture 38j has a lengthwhich is substantially greater than the length illustrated in FIG. 2.The cylindrical anchor 50j, with the suture 38j connected thereto, isthen positioned in axial alignment with the tubular member 240 whichextends through the passage 40j. Thus, the anchor 50j is moved to anorientation in which a longitudinal central axis of the anchor iscoincident with the longitudinal central axis of the cylindrical passage246 in the tubular member 240 which extends through the passage 40j inthe bone 20j.

The leading end 58j of the anchor 50j is then moved into the cylindricaltubular member 240 which forms a liner for the passage 40j. A pushermember pushes the anchor 50j from an upper (as viewed in FIG. 13) end244 of the tubular member 240 along the passage 246 in the tubularmember 240 and the passage 40j in the bone 20 and through the outlet 84jfrom the passage. As the anchor 50j moves through the passages 40j and246, the suture 38j is pulled through the passages by the anchor.

The orientation of the anchor 50j is then changed from an orientation inwhich the longitudinal central axis of the anchor 50j is aligned withthe coincident longitudinal central axes of the passages 40j and 246 toan orientation in which the longitudinal central axis of the anchor 50jextends generally perpendicular to the longitudinal central axis of thepassages 40j and 246, i.e., the orientation shown in FIG. 13. To pivotthe anchor 50j to the orientation shown in FIG. 13, as the anchoremerges from the outlet 84, the suture 38j is tensioned. The combinationof the tension in the suture 38j and force applied against the trailingend 60j of the anchor 50j by the pusher member causes the anchor topivot about the trailing end 60j of the anchor. The pusher member isthen withdrawn and the suture 38j tensioned to move the anchor to theposition shown in FIG. 13 in a manner similar to that described in theaforementioned U.S. Pat. Nos. 5,527,343 and 5,534,012.

Although it is believed that it may be preferred to change theorientation of the anchor 50j after it has emerged from the passages 40jand 246, the anchor could be blocked from reentering the passage inother ways if desired. Thus, the anchor could expand after emerging fromthe passages 40j and 246. This could be accomplished by having springbiased arms held in a retracted position by engagement of spring biasedarms with the inner side surface of the tubular cylindrical member 240which lines the passage 40j. Upon emerging from the passages 40j and246, the arms would move outward under the influence of spring forcesand extend radially outward beyond the edge of the exit from the passage40j. If desired, the anchor 50j could be constructed so as to expand ina manner similar to that disclosed in U.S. Pat. No. 5,397,331 and/orU.S. Pat. No. 4,409,974.

Rather than expanding under the influence of stored energy, such asspring force, the anchor 50j could expand by absorbing body fluids.Thus, the anchor 50j may be compressed when it moves through thepassages 40j and 246 and will expand and absorb body fluids afteremerging from the passages 40j and 246. It is contemplated that theanchor 50j could be constructed so as to expand in any one of the waysdisclosed in U.S. patent application Ser. No. 08/699,553 filed Aug. 19,1996 by Peter M. Bonutti and entitled "Suture Anchor".

Once the anchor 50j has been moved through the passage 246, the passageis packed with bone particles and/or bone graft. The bone particlesand/or bone graft contains bone growth inducing materials. In addition,the bone particles and/or bone graft may contain medicinal substancesalong with osteoinductive protein.

The limbs 72j and 74j of the suture 38j are then threaded throughopenings 64j and 66j in the second suture anchor 52j. The limbs 72j and74j of the suture 38j are tensioned and the second anchor 52j is pressedagainst the outer side surface 250 of the bone 20j. While apredetermined tension force is maintained in the limbs 72j and 74j ofthe suture 38j, the knot 78j is tied in the suture to interconnect thetwo suture anchors 50j and 52j with the suture 38j. The suture 38j isthen trimmed to the desired length.

Once the knot 78j has been tied between the limbs 72j and 74j of thesuture 38j, the tension in the suture 38j presses the side surfaces 28jand 30 of the fracture 26j together. This pressure between the sidesurfaces 28 and 30j of the fracture 26j is maintained by the suture 38and suture anchors 50j and 52j until the fracture heals. It is believedthat it may be preferred to form the suture 38j and suture anchors 50jand 52j of a biodegradable material which, after the fracture 26j hashealed, will dissolve in the patient's body.

The cylindrical tubular member 240 which is inserted into the passage40j through the bone 20j performs the dual functions of lining theinside of the passage 40j and maintaining the two sections 22j and 24jof the bone in alignment. The cylindrical tubular member 240 could havea slot formed in a side wall of the tubular member to facilitateinsertion of the tubular member into the passage 40j. It is contemplatedthat the cylindrical tubular member 240 could be left in the passage 40jafter the bone securing assembly 32j has been installed. If the slottedor unslotted cylindrical tubular member 240 is to be left in the passage40j, the cylindrical tubular member 240 may be formed of a biodegradableor bioerodible copolymer. When the cylindrical tubular member remains inthe passage 40j, the suture 38j extends through the tubular member.

Although only a knot 78j has been shown in FIG. 13 adjacent to thesecond anchor 52j, a suture retainer could be provided to further holdthe limbs 72j and 74j of the suture 38j. If a suture retainer is to beused in association with the knot 78j, the suture retainer will be movedalong the limbs of the suture 38j toward the knot before the limbs 72jand 74j of the suture are trimmed to the short length shown in FIG. 13.The suture retainer would then be plastically deformed to grip the limbs72j and 74j of the suture 38j. Thereafter, the suture limbs 72j and 74jwould be trimmed to a desired length.

Although it is preferred to use a suture as the force transmittingmember 38j, it should be understood that the anchors 50j and 52j couldbe interconnected by other force transmitting members, such as a rodformed of bone. Although the anchors 50j and 52j have constructionswhich enable them to be used with a suture, the anchors could beconstructed so as to be used with other types of force transmittingmembers. For example, the anchors 50j and 52j could have threadconvolutions to engage thread convolutions on a force transmittingmember formed by a rod.

In the embodiment of the invention illustrated in FIG. 13, the member240 is tubular. However, it is contemplated that a solid member could beused to transmit force to bone on opposite sides of the fracture 26j.Thus, the member 240 could be a solid cylindrical member formed of bone.The cylindrical member may be formed of freeze dried bone.

When the member 240 is a solid member, the suture or other forcetransmitting member 38j is eliminated. The solid member formed of bonebecomes the force transmitting member. Anchors, corresponding to theanchors 50j and 52j, are connected to opposite ends of the solid member240 formed of bone. The anchors may have internal thread convolutionswhich engage external thread convolutions on the solid member 240 formedof bone. Of course, other known connectors could be utilized to connectanchors with opposite ends of the solid member 240 formed of bone.

Nonlinear Suture Passage--Tubular Member

In the embodiment of the invention illustrated in FIG. 13, the passage40j through which the suture 38j extends has a linear configuration. Inthe embodiment of the invention illustrated in FIG. 14, the passagethrough which the suture extends has a nonlinear configuration. Sincethe embodiment of the invention illustrated in FIG. 14 is generallysimilar to the embodiment of the invention illustrated in FIGS. 1--13,similar numerals will be utilized to identify similar components, thesuffix letter "k" being associated with the components of the embodimentof the invention illustrated in FIG. 14 to avoid confusion.

A bone 20k as a fracture 26k which divides the bone into two sections22k and 24k. Opposite side surfaces 28k and 30k of the fracture 26k arepressed together by a bone suture assembly 32k. The bone suture assembly32k includes a suture 38k which extends between first and second sutureanchors 50k and 52k.

The suture 38k is disposed in a passage 40k having a nonlinearconfiguration. Thus, the passage 40k includes a first section 140k whichis skewed relative to a second section 142k of the passage 40k. A bend144k is formed in the passage 40k at an intersection 146k of the firstand second sections 140k and 142k of the passage 40k. The flexiblesuture 38k extends around the bend 144k along a nonlinear path betweenthe suture anchors 50k and 52k. At the bend 144k, the suture 38k appliesforce against the section 24k of the bone 20k urging the section 24ktoward the left (as viewed in FIG. 5). This force presses the sections22k and 24k of the bone 20k firmly together at the fracture 26k.

The suture anchors 50k and 52k have the same cylindrical construction asthe suture anchors 50, 52, 50j and 52j in the embodiment of theinvention illustrated in FIGS. 2 and 13. A knot 78k (FIG. 14) isprovided between limbs of the suture 38k to maintain a desired tensionin the suture 38k. This tension pulls the suture anchors 50k and 52ktoward each other. In addition, this tension presses the section 24k ofthe bone 20k firmly against the section 22k of the bone at the fracture26k.

The first section 140k of the passage 40k is formed at an angle to andextends through a longitudinal central axis of the generally cylindricalbone 20k. The second section 142k of the passage 40k is formed in adirection perpendicular, i.e., along a radius, of the generallycylindrical bone 20k. The two sections 140k and 142k of the passage 40kterminate in the spongy cancellous bone tissue 44k.

When the suture assembly 32k is to be used to treat the fracture 26k inthe bone 20k, the two sections 22k and 24k of the bone are pressedtogether at the fracture 26k to align the side surfaces 28k and 30k ofthe fracture. A drill or other hole forming apparatus is then used toform the first section 140k of the passage 40k. The drill or other holeforming apparatus is then used to form the second section 142k of thepassage 40k. When the second section 142k of the passage 40k intersectsthe first section 140k of the passage 40k, formation of the section 142kof the passage 40k is interrupted.

Once the nonlinear passage 40k has been formed in the two sections 22kand 24k of the bone 20k, a tubular cylindrical liner 240k is insertedinto the passage 40k. The tubular cylindrical liner 240k is formed bytwo separate cylindrical tubular members 252 and 254 which are insertedat opposite ends of the passage 40k. Alternatively, the tubularcylindrical liner 240k may be formed by a single flexible tubular memberwhich is inserted into the section 140k of the passage 40k and thenmoved around the bend 144k into the section 142k of the passage 40k.

It is believed that it may be preferred to form the tubular members 252and 254 of bone. The bone forming the tubular members 252 and 254 may beeither human or animal bone. The tubular members 252 and 254 may beformed of freeze dried human bone.

The leading end 242k of the tubular member 252 is disposed in thecompact outer layer 42k of the bone 20k. Similarly, the trailing end244k of the tubular member 254 is disposed in the compact outer layer42k of the bone 20k. The tubular member 252 extends across the fracture26k and stabilizes the two sections 22k and 24k of the bone 20k. Sincethe end portions 242k and 244k of the tubular members 252 and 254 aredisposed in the compact outer layer 42k of the bone 20k, the tubularmembers are solidly supported and hold the two sections 22k and 24k ofthe bone 20k in alignment at the fracture 26k.

The opposite ends 242k and 244k of the tubular members 252 and 254 areaxially spaced from a generally cylindrical outer side surface 250k onthe bone 20k. This enables the anchors 50k and 52k to be pressed againstthe outer side surface 250k of the bone 20k. Therefore, tension forcesin the suture 38k are transmitted through the anchors 50k and 52k to thebone 20k.

The cylindrical anchor 50k, with the suture 38k connected thereto, isthen positioned in axial alignment with the section 142k of the passage40k. The leading end 58k of the anchor 50k is then moved into thesection 142k of the passage 40k lined by the tubular member 254. Aflexible pusher member applies force against the trailing end 60k of theanchor 50k and pushes the anchor around the bend 144k and through thesection 140k of the passage 40k lined by the tubular member 252.

Alternatively, a flexible wire or other member could be inserted intothe section 140k of the passage 40k. The wire would move around the bend144k and extend outward from the section 142k of the passage. The wirewould then be connected with the anchor 50k and suture 38k. The leadingend 58k of the anchor 50k would then be inserted into the section 142kof the passage 40k. Tension on the wire would pull the anchor 50k aroundthe bend 144k and out of the section 140k of the passage 40k.

The passages in the tubular members 252 and 254 may be packed with boneparticles and/or bone graft. Bone osteoinductive protein (BMP) may beprovided in the tubular members. Antibiotics and/or other medicants maybe included along with collagen.

The suture 38k is then threaded through openings in the suture anchor52k. The suture 38k is then tensioned and the second anchor 52k ispressed against the outer side surface of the bone 20k. While apredetermined tension force is maintained in the suture 38k, the knot78k is tied.

In the illustrated embodiment of the invention, the two sections 140kand 142k of the passage 40k have a straight cylindrical configuration.However, it is contemplated that the sections 140k and 142k of thepassage 40k could have a different configuration if desired. Forexample, the section 140k and/or 142k of the passage 40k could have anonlinear central axis and could have a noncircular cross-sectionalconfiguration of desired.

Body tissue, corresponding to the body tissue 132 of FIG. 4 could bedisposed between the anchor 50k and/or 52k and the bone 20k. Althoughthe suture 38k has been illustrated as having a pair of limbs orsections which extend between the anchors 50k and 52k, the suture 38kcould have a single limb or section if desired. The anchor 50c couldmechanically expand, by absorbing body liquid or under the influence ofexpansion springs, after the anchor has emerged from the passage 40k toprevent the anchor from being pulled back through the passage.

Retainer and Tubular Member

In the embodiment of the invention illustrated in FIG. 13, a pair ofsuture anchors 50j and 52j are connected with the suture 38j to maintaintension in the suture and pressure against opposite side surfaces 28jand 30j of the fracture 26j. In the embodiment of the inventionillustrated in FIG. 15, a suture retainer is used in place of one of thesuture anchors. Since the embodiment of the invention illustrated inFIG. 15 is generally similar to the embodiment of the inventionillustrated in FIG. 13, similar numerals will be utilized to designatesimilar components, the suffix letter "m" being associated with theembodiment of the invention illustrated in FIG. 15 to avoid confusion.

A bone 20m has sections 22m and 24m which are separated by a fracture26m. The fracture 26m has side surfaces 28m and 30m which are pressedtogether by a bone suture assembly 32m. A suture 38m extends through acylindrical passage 40m which extends diametrically through thegenerally cylindrical bone 20m. The suture 38m has a pair of limbs orsections 72m and 74m which are connected with a suture anchor 50m. Thesuture anchor 50m has the same construction as the suture anchor 50 ofFIG. 2.

Once the passage 40 has been formed in the two tubular sections 22m and24m of the bone 20m, a tubular cylindrical member 240m is installed intothe passage 40m and extends diametrically through the bone 20m. Theleading end 242m of the cylindrical member 240m is aligned with acircular outlet 84m from the passage 40m. The opposite or trailing end244m of the tubular member 240m is aligned with a circular inlet 86m tothe passage 40m.

The tubular member 240m has a thin cylindrical wall which engages thesections 22m and 24m of the bone 20m. A cylindrical inner side surfaceof the tubular member 240m defines a cylindrical passage 246m having adiameter which is only slightly less than the diameter of the passage40m. The tubular member 240m is formed of bone. Alternatively, thetubular member 240m could be formed of a biodegradable material.

The leading end 242m of the tubular member 240m is disposed in thecompact outer layer 42m of the bone 20m. Similarly, the trailing end244m of the tubular member 240m is disposed in the compact outer layer42m of the bone 20m. The tubular member 240m extends across the fracture26m and stabilizes the two sections 22m and 24m of the bone 20m. Sincethe opposite end portions of the tubular member 240m are disposed in thecompact outer layer 42m of the bone 20m, the tubular member is solidlysupported and holds the two sections 22m and 24m of the bone 20m inalignment at the fracture 26m.

The opposite ends 242m and 244m of the tubular member 240m are axiallyspaced from a generally cylindrical outer side surface 250m on the bone20m. This enables the anchors 50m and 92m to be pressed against theouter side surface 250m of the bone 20m. Therefore, tension forces inthe suture 38m are transmitted through the anchors 50m and 92m to thebone 20m.

The tubular member 240m is formed of freeze dried human bone. Thetubular member 240m is packed with bone and/or bone graft. The tubularmember 240m also contains bone osteoinductive protein (BMP). Suitablemedicants may be provided in the tubular member 240m.

A suture retainer 92m is used in place of the suture anchor 52 of FIG.2. The suture retainer 92m (FIG. 15) has a spherical configuration. Acylindrical passage 94m extends through the center of the sphericalsuture retainer 92m. The sections 72m and 74m of the suture 38m extendaround the spherical outer side surface of the suture retainer 92m.Thus, a loop is formed in each of the sections 72m and 74m aroundportions of the suture retainer 92m.

If desired, the suture retainer 92m could have a differentconfiguration. For example, the suture retainer 92m could have an ovalor elliptical configuration. Although the passage 94m has a linearcentral axis, the passage could have a nonlinear central axis. Ifdesired, a plurality of passages having the same or differentconfigurations could be provided in the suture retainer 92m.

After the suture 38m has been inserted through the suture retainer 92m,the suture retainer 92m is moved along the sections 72m and 74m of thesuture 38m toward the bone 20m. The suture retainer 92m is formed as onepiece of a polymeric material having a relatively low coefficientfriction. Therefore, the two sections 72m and 74m of the suture 30m canreadily slide along the surfaces of the suture retainer 52m while thesuture retainer moves toward the bone 20m.

A predetermined tension is maintained in the sections 72m and 74m of thesuture 38m while the suture retainer 92m is pressed against the bone20m. This results in the suture 38m being pulled tightly against thesuture anchor 50m. The tension in the suture 38m is effective to pressthe suture anchor 50m and retainer 92m against opposite sides of thebone 20m with a predetermined force.

While the sections 72m and 74m of the suture 38m are being tensionedwith a predetermined force, the suture retainer 92m is plasticallydeformed in the same manner as previously described in conjunction withthe embodiment of the invention illustrated in FIG. 3. To plasticallydeform the suture retainer 92m, a plurality of force applying or clampmembers are pressed against the suture retainer with a predeterminedminimum force. The force applied against the suture retainer 92m by theforce applying members is sufficient to cause plastic deformation of thematerial of the suture retainer.

The force is applied against the suture retainer 92m while the sutureretainer is at a temperature which is below the transition temperatureof the biodegradable polymer which forms the suture retainer 92m. Thus,the suture retainer 92m is at approximately the same temperature as thebone 20m when the force is applied against the suture retainer. Theforce causes the material of the suture retainer 92m to flow and gripthe sections 72m and 74m of the suture 38m.

The suture retainer 92m may be formed of many different materials.However, it is believed that it will be preferred to form the sutureretainer 92m of a biodegradable polymer. One biodegradable polymer whichmay be utilized is polycaperlactone. Alternatively, the suture retainer92m could be formed of polyethylene oxide terephthalate or polybutyleneterephthalate. It is also contemplated that other biodegradable orbioerodible copolymers could be utilized.

Although it is preferred to form the suture retainer 92m of abiodegradable material, the suture retainer could be formed of amaterial which is not biodegradable. For example, the suture retainer92m could be formed of an acetyl resin, such as "DELRIN" (trademark).Alternatively, the suture retainer 92m could be formed ofpara-dimethylamino-benzenediazo sodium sulfonate, such as "DEXON"(trademark). The construction of the suture retainer 92m and the mannerin which is cooperates with the suture 38m is the same as is disclosedin U.S. patent application Ser. No. 08/905,084 filed Aug. 1, 1997 byPeter M. Bonutti et al. and entitled "Method and Apparatus for Securinga Suture".

The suture retainer 92m is plastically deformed to grip the limbs 72mand 74m of the suture 38m. However, the suture retainer 92m could beconstructed so as to be mechanically actuated to grip the suture 38m. Ifdesired, a combination of a mechanical gripping action and plasticdeformation could be utilized by a retainer to grip the suture 38m.

Conclusion

In view of the foregoing description, it is apparent that the presentinvention relates to a method of securing sections 22 and 24 of afractured bone 20. Sections 22 and 24 of a fractured bone 20 are heldagainst movement relative to each other by a force transmitting member,such as a suture 38, which extends through a passage 40 in the bone. Thepassage 40 in the bone may have a linear or nonlinear configuration.Tension is maintained in the force transmitting member 38 to presssurfaces 28 and 30 on the fracture together by securing anchors 50 and52 or suture retainers 92 to opposite ends of the force transmittingmember 38. It is believed that a suture 38 may advantageously be used asthe force transmitting member.

A tubular member 240 is positioned in a linear passage (FIGS. 13 and 15)or a nonlinear passage (FIG. 14) through the bone 20. The tubular member240 extends into portions of the passage 40 on opposite sides of thefracture 26. End portions of the tubular member may be positioned in acompact outer layer 42 of the bone. The tubular member 240 may be formedof bone. The force transmitting member 38 may be formed of bone or otherbody tissue.

Having described the invention, the following is claimed:
 1. A method oftreating a fractured bone, said method comprising the steps of forming apassage extending through bone on opposite sides of the fracture,positioning a tubular member in the passage with the tubular memberextending into portions of the passage on opposite sides of thefracture, positioning a suture in the tubular member, positioning firstand second anchors adjacent to bone on opposite sides or the fracturewith the anchors and suture interconnected, and transmitting forcethrough the suture to the first and second anchors to urge bone onopposite sides of the fracture together while at least a portion of thesuture is disposed in the tubular member.
 2. A method as set forth inclaim 1 wherein said step of positioning first and second anchors inengagement with bone on opposite sides of the fracture with the anchorsand suture interconnected includes moving the first anchor through thetubular member while the first anchor is connected with the suture.
 3. Amethod as set forth in claim 2 wherein said step of positioning firstand second anchors adjacent to bone on opposite sides of the fracturewith the anchors and suture interconnected includes connecting thesecond anchor with the suture after performing said step of moving thefirst anchor through the tubular member.
 4. A method as set forth inclaim 1 wherein said step of positioning first and second anchorsadjacent to bone on opposite sides of the fracture with the anchors andsuture interconnected includes moving the first anchor through thetubular member with the first anchor in a first orientation, andchanging the orientation of the first anchor from the first orientationto a second orientation after having performed said step of moving thefirst anchor through the tubular member, said steps of moving the firstanchor through the tubular member and changing the orientation of thefirst anchor being performed with the suture connected with the firstanchor.
 5. A method as set forth in claim 1 wherein said step ofpositioning first and second anchors adjacent to bone on opposite sidesof the fracture with the anchors and suture interconnected includessecuring the suture relative to the second anchor by tying a knot in thesuture.
 6. A method as set forth in claim 1 wherein said step ofpositioning first and second anchors adjacent to bone on opposite sidesof the fracture with the anchors and suture interconnected includesdeforming a suture retainer to grip the suture with the suture retainer.7. A method as set forth in claim 1 wherein said step of positioning atubular member in the passage includes positioning the tubular member inthe passage with a first end of the tubular member disposed adjacent toand spaced apart from an outer side surface of the bone on a first sideof the fracture, with a second end of the tubular member disposedadjacent to and spaced apart from an outer side surface of the bonedisposed on a second side of the fracture, and with a portion of thetubular member disposed between the first and second ends of the tubularmember extending across the fracture.
 8. A method as set forth in claim1 wherein said step of positioning a tubular member in the passageincludes positioning the tubular member in the passage with a first endportion of the tubular member disposed in engagement with a compactouter layer of the bone on a first side of the fracture and with asecond end portion of the tubular member disposed in engagement with acompact outer layer of the bone on a second side of the fracture.
 9. Amethod as set forth in claim 1 further including the step of packing thetubular member with bone particles.
 10. A method as set forth in claim 1wherein said step of positioning a tubular member in the passageincludes positioning a tubular member formed of bone in the passage. 11.A method as set forth in claim 10 further including the step of packingthe passage in the tubular member formed of bone with boneosteoinductive protein.
 12. A method of treating a fractured bone, saidmethod comprising the steps of forming a passage extending through boneon opposite sides of the fracture, positioning a tubular member in thepassage, positioning a suture in the passage with a portion of thesuture extending through the tubular member and with a portion of thesuture connected with an anchor disposed adjacent to a first end of thepassage, tensioning the suture to transmit force from the suture to theanchor, gripping a portion of the suture with a retainer disposedadjacent to a second end of the passage, and transmitting force throughthe suture to the anchor and retainer to urge opposite sides of thefracture together while at least a portion of the suture is disposed inthe tubular member.
 13. A method as set forth in claim 12 wherein saidstep of gripping the suture with the retainer includes deformingmaterial of the suture retainer.
 14. A method as set forth in claim 12further including the step of moving the retainer along the suture intoengagement with the bone with the suture retainer spaced from thetubular member, said step of transmitting force through the suture tothe anchor and retainer includes pressing the retainer against the boneon a side of the fracture.
 15. A method as set forth in claim 12 whereinsaid step of positioning the suture in the passage with a portion of thesuture extending through the tubular member includes moving the anchorthrough the tubular member while the anchor is connected with thesuture.
 16. A method as set forth in claim 12 further including the stepof changing the orientation of the anchor relative to the tubular memberafter having performed said step of moving the anchor through thetubular member.
 17. A method as set forth in claim 12 wherein said stepof positioning a tubular member in the passage includes positioning thetubular member in the passage with a first end of the tubular memberdisposed adjacent to and spaced apart from an outer side surface of thebone disposed on a first side of the fracture, with a second end of thetubular member disposed adjacent to and spaced apart from an outer sidesurface of the bone disposed on a second side of the fracture, and witha portion of the tubular member disposed between the first and secondends of the tubular member extending across the fracture.
 18. A methodas set forth in claim 12 wherein said step of positioning a tubularmember in the passage includes positioning the tubular member in thepassage with a first end portion of the tubular member disposed inengagement with a compact outer layer of the bone on a first side of thefracture and with a second end portion of the tubular member disposed inengagement with the compact outer layer of the bone on a second side ofthe fracture.
 19. A method as set forth in claim 12 further includingthe step of packing the tubular member with bone particles.
 20. A methodas set forth in claim 12 wherein said step of positioning a tubularmember in the passage includes positioning a tubular member formed ofbone in the passage.
 21. A method as set forth in claim 20 furtherincluding the step of packing the passage in the tubular member formedof bone with bone osteoinductive protein.
 22. A method of treating afractured bone, said method comprising the steps of forming a nonlinearpassage which extends across the fracture from bone on a first side ofthe fracture to bone on a second side of the fracture, positioning atubular member in the nonlinear passage with the tubular memberextending across the fracture, positioning anchors adjacent to oppositeends of the nonlinear passage with a suture extending between theanchors and through the tubular member, and transmitting force throughthe suture to the anchors to urge the bone on opposite sides of thefracture together while at least a portion of the suture is disposed inthe tubular member.
 23. A method as set forth in claim 22 wherein saidstep of positioning anchors adjacent to opposite ends of the nonlinearpassage with a suture extending between the anchors and through thetubular member includes moving an anchor connected with the suturethrough the nonlinear passage.
 24. A method as set forth in claim 22further including the step of packing the tubular member with boneparticles.
 25. A method as set forth in claim 22 wherein said step ofpositioning a tubular member in the passage includes positioning atubular member formed of bone in the passage.
 26. A method as set forthin claim 25 further including the step of packing the passage in thetubular member formed of bone with bone osteoinductive protein.
 27. Amethod of treating a fractured bone having a compact outer layer whichencloses cancellous bone, said method comprising the steps of forming apassage which extends through the compact outer layer on a portion ofthe bone disposed on a first side of the fracture, through thecancellous bone on opposite sides of the fracture, and through thecompact outer layer on a portion of the bone on a second side of thefracture, positioning a tubular member in the passage with a first endportion of the tubular member in engagement with the compact outer layeron the portion of the bone on the first side of the fracture, with asecond end portion of the tubular member in engagement with the compactouter layer on the portion of the bone on the second side of thefracture, and with a portion of the tubular member disposed between thefirst and second end portions of the tubular member in engagement withthe cancellous bone on opposite sides of the fracture, positioninganchors adjacent to opposite ends of the passage with a suture extendingbetween the anchors and through the tubular member, and transmittingforce through the suture to the anchors to urge the portions of the boneon the first and second sides of the fracture toward each other while atleast a portion of the suture is disposed in the tubular member.
 28. Amethod as set forth in claim 27 wherein said step of positioning anchorsadjacent to opposite ends of the passage with the suture extendingbetween the anchors and through the tubular member includes moving oneof the anchors through the tubular member while the one anchor isconnected with the suture.
 29. A method as set forth in claim 27 whereinsaid step of positioning tubular member in the passage includespositioning the tubular member in the passage with the first end portionof the tubular member spaced apart from an outer side surface of thecompact outer layer on the portion of the bone on the first side of thefracture and with the second end portion of the tubular member spacedapart from an outer side surface of the compact outer layer on theportion of the bone on the second side of the fracture.
 30. A method asset forth in claim 27 wherein said step of positioning anchors adjacentopposite ends of the passage with the suture extending between theanchors and through the tubular member includes moving one of theanchors in the tubular member with the one anchor in a first orientationand with the suture connected with the one anchor in a first orientationand with the suture connected with the one anchor, moving the one anchorout of the tubular member, and changing the orientation of the oneanchor from the first orientation to a second orientation, said step oftransmitting force through the suture to the anchors being performed witthe one anchor in the second orientation.
 31. A method as set forth inclaim 27 further including the step of packing the tubular member withbone particles.
 32. A method as set forth in claim 27 wherein said stepof positioning a tubular member in the passage includes positioning atubular member formed of bone in the passage.
 33. A method as set forthin claim 32 further including the step of packing the passage in thetubular member formed of bone with bone osteoinductive protein.
 34. AMethod of treating a fractured bone, said method comprising the steps offorming a passage extending through bone on opposite sides of thefracture, positioning a tubular member in the passage with the tubularmember extending into portions of the passage on opposite sides of thefracture, positioning a force transmitting member in the tubular member,positioning first and second anchors adjacent to bone on opposite sidesor the fracture with the anchors and force transmitting memberinterconnected, and transmitting force through the force transmittingmember to the first and second anchors to urge bone on opposite sides ofthe fracture together while at least a portion of the force transmittingmember is disposed in the tubular member.
 35. A method as set forth inclaim 34 wherein said step of positioning first and second anchors inengagement with bone on opposite sides of the fracture with the anchorsand force transmitting member interconnected includes moving the firstanchor through the tubular member while the first anchor is connectedwith the force transmitting member.
 36. A method as set forth in claim35 wherein said step of positioning first and second anchors adjacent tobone on opposite sides of the fracture with the anchors and forcetransmitting member interconnected includes connecting the second anchorwith the force transmitting member after performing said step of movingthe first anchor through the tubular member.
 37. A method as set forthin claim 34 wherein said step of positioning first and second anchorsadjacent to bone on opposite sides of the fracture with the anchors andforce transmitting member interconnected includes moving the firstanchor through the tubular member with the first anchor in a firstorientation, and changing the orientation of the first anchor from thefirst orientation to a second orientation after having performed saidstep of moving the first anchor through the tubular member, said stepsof moving the first anchor through the tubular member and changing theorientation of the first anchor being performed with the forcetransmitting member connected with the first anchor.
 38. A method as setforth in claim 34 wherein the force transmitting member is a suture andsaid step of positioning first and second anchors adjacent to bone onopposite sides of the fracture with the anchors and force transmittingmember interconnected includes securing the suture relative to thesecond anchor by tying a knot in the suture.
 39. A method as set forthin claim 34 wherein the force transmitting member is a suture and saidstep of positioning first and second anchors adjacent to bone onopposite sides of the fracture with the anchors and force transmittingmember interconnected includes deforming a suture retainer to grip thesuture with the suture retainer.
 40. A method as set forth in claim 34wherein said step of positioning a tubular member in the passageincludes positioning the tubular member in the passage with a first endof the tubular member disposed adjacent to and spaced apart from anouter side surface of the bone on a first side of the fracture, with asecond end of the tubular member disposed adjacent to and spaced apartfrom an outer side surface of the bone disposed on a second side of thefracture, and with a portion of the tubular member disposed between thefirst and second ends of the tubular member extending across thefracture.
 41. A method as set forth in claim 34 wherein said step ofpositioning a tubular member in the passage includes positioning thetubular member in the passage with a first end portion of the tubularmember disposed in engagement with a compact outer layer of the bone ona first side of the fracture and with a second end portion of thetubular member disposed in engagement with a compact outer layer of thebone on a second side of the fracture.
 42. A method as set forth inclaim 34 further including the step of packing the tubular member withbone particles.
 43. A method as set forth in claim 34 wherein said stepof positioning a tubular member in the passage includes positioning atubular member formed of bone in the passage.
 44. A method as set forthin claim 43 further including the step of packing the passage in thetubular member formed of bone with bone osteoinductive protein.
 45. AMethod of treating a fractured bone, said method comprising the steps offorming a passage extending through bone on opposite sides of thefracture, positioning a tubular member formed of bone in the passagewith the tubular member formed of bone extending into portions of thepassage on opposite sides of the fracture, and placing bone growthinducing materials in the tubular member formed of bone.
 46. A method asset forth in claim 45 wherein said step of placing bone growth inducingmaterials in the tubular member formed of bone includes placing boneparticles in the tubular member formed of bone.
 47. A method as setforth in claim 45 wherein said step of placing bone growth inducingmaterials in the tubular member formed of bone includes placing bonegraft in the tubular member.
 48. A method as set forth in claim 45wherein said step of placing bone growth inducing materials in thetubular member formed of bone includes placing osteoinductive protein inthe tubular member formed of bone.
 49. A method as set forth in claim 45wherein said step of placing bone growth inducing materials in thetubular member formed of bone is performed after performing said step ofpositioning the tubular member formed of bone in the passage.
 50. Amethod as set forth in claim 45 further including the steps ofpositioning a force transmitting member in the tubular member andtransmitting force through the force transmitting member to bone onopposite sides of the fracture.
 51. A method as set forth in claim 50further including the step of positioning anchors adjacent to oppositeends of the tubular member and transmitting force through the forcetransmitting member to the anchors.
 52. A method as set forth in claim50 wherein said step of positioning a force transmitting member in thetubular member includes positioning a force transmitting member formedof bone in the tubular member.
 53. A method as set forth in claim 45wherein said step of positioning a tubular member formed of bone in thepassage includes positioning a tubular member formed of freeze driedbone in the passage.
 54. A Method of treating a fractured bone, saidmethod comprising the steps of forming a passage extending through boneon opposite sides of the fracture, positioning a member formed of bonein the passage with the member formed of bone extending into portions ofthe passage on opposite sides of the fracture, and transmitting forcethrough the member formed of bone to bone on opposite sides of thefracture to urge bone on opposite sides of the fracture together.
 55. Amethod as set forth in claim 54 further including the steps ofconnecting a first anchor with a first end portion of the member formedof bone, and connecting a second anchor with a second end portion of themember formed of bone.
 56. A method as set forth in claim 54 whereinsaid member formed of bone has a tubular configuration, said methodfurther includes the steps of positioning a force transmitting member inthe member formed of bone, said step of transmitting force through themember formed of bone to bone on opposite sides of the fracture includestransmitting force through the force transmitting member while the forcetransmitting member is at least partially enclosed by the member formedof bone.